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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ---- -- ---------- ----- --- - ------ --- -- (Complete in Triplicate) -------------- -- ---------- t --�- �--- --- Date Issued This Permit Expires 1 Year From Date issued Application is hereby made to the San JoaquinoLocal Health District for a permit to construct and install the work herein described. This application is made"in compliance with Coupty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION � � r 77 --- ----CENSUS TRACT ----------- -- ------------ ------Phone3-6.9. ---------------Phone3_6.9.--_-2-0-7f-16 Owner's Name Address City ,"c i � ..License # .-/QCJ_a_�- Phone ------------------------------ Contractor's Nam P�`° Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court Motel ❑Other ------------- ------------------------------ Number of living units:__--I----- Number of bedrooms _ ----Garbage Grinder ___--____ - Lot Size --------------------------------------------- Water Supply: Public System and name ------------------ ---- ------------------------------------------------------- y Private`` Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam' Clay Loam ❑ Hardpan ❑ Adob Fill Material ------------ If yes, type ._______-°____________ iPlot plan, showing size of lot, location of system in relation latito wells, buildings,"etc. must be placed on reverse side.] a NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK�<, p Size__ _ - -------- �t-------- Liquid Depth. ------- Q Capacity �f�- ------- TYPer ��' " ' _ Materiah - No. Compartments ----- ----<•--- / �p Distance .to- nearest: Wel! Foundation ------ -- -------- Prop. Line ------------- LEACHING LINE -�-ZNo. of Lines-___.. ------------- ---- Length of eacfi line_.__-c�.�-.- Total Length .______1-6-�_-..---- x� t _ _ e ", D' Box --'1___._..- Type Filter Material ---Depth Filter Material __- +�. w' f F ,�� -___.__ Property Line - Distance to nearest: Well ---------`-"---4Fo dation -- ------------- --- ------ SEEPAGE PIT Depth Diameter �_'_°------------ Number.._._,-... Rock Filled Yes ❑ No i❑ - %J * _ : , p i Water Table Depth --------------------------------Rock Siie -----------------------------'- --------------- 1 Foundation Pro Line ---------------------- 1 ------------- - -- Qistance to nearest: Wel!'------------------------------------------ ---------- -�------ p• - - -- ori Permit#-----�--------------------------- ------ Date �-------------------- REPAIR/ADDITION ) } (Prev. Sanitation } I -------------------------- Septic ( p yRequirements) ---------__------ - ----------------------------------- ------- --------------------------------------- Disposal ---------.---- - --- Disposal Field (Specify Requirements) __..___-___-- - - --- - j------------------ ------ -------------------- --------------------------`----- -------------------------- -------- (Draw existing and required addition on reverse side) 3 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance.of the work for which this permit is issued, I shall not employ any person in such manner as to bet blect to Wo kman's Compensation laws of California." s g4j___ � .-� C-S- -- -� ---- 5 i ne - TENT ------ Title --------- ----- (If other than owner) Ali I FOR .DELOSE ONLY APPLICATION ACCEPTED BY -___: __ ----------------- DATE ------------- BUILDING PERMIT ISSUED ----------- ------- - ---------- -- ----DATE.------- ----------------------------------- ADDITIONAL ----•----------------- ------ADDITIONAL COMMENTS ----------`!------------------------------------------------------------- - --------------------------------- --------------- --------- -------------------------------------------- ----------------------------------------------- --------------------------------------------- -------- --------- ---------- -------------------------------- ----- --------- - �r'- Final Inspection by: _.__. _- -- - -=ii- - ----- ------------------- -----.Dated �- - �------------ t SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M.