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FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMIT Permit No... (Complet&n Triplicate) -- Date Issued -_7.�f�?. __________ This Permit Exp/ — - ires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules?"and Regulations: --CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION .-- ---- '� = i� r�-. ------=- Phone' Owner's Name /� -.t'y- --- .------- .t' "~ ---------- - --------- !+' ----•- Address `�_.- . ' ' 't- .fi',i ---------�� Cit �_r-_�- "`"+� �----------- Contractor's Name ----------C., ------ - -------------.License # Phone Installation will serve: Residence jrApartment House El Commercial ❑Trailer Court l❑ Motel ❑Other -------------------------------------------- Number ------------- ----------------------------Number of living units:----/--- Number of bedrooms -- _---Garbage Grinder _ "-- Lot Size ? ------------•Private . System - .. ,- ---- Clay .Peat Sandy Loam ---_------ Water Supply: Public and name ------ 1�=�" � ��---- Character of soil to a depth of 3 feet. Sand ❑ Silt❑ y ❑ ❑ ❑ Clay Loam Hardpan ❑ Adobe k Fill Material ------------ If yes, type ---------_------------- ---(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r O t r d '- t PACKAGE TREATMENT ASEPTIC TANK [ Size---+ - 1�� ------ Liquid Depth --`1- -------------.:--.• Capacity Type �- � Material--- ---------- --- No. Compartments --- ---------=---• V i .—� r Distance to nearest: Well ....�'��------------------------- Foundation __/�_'_---------- Prop. Line _-- _.._---_.:'----._-- [r� LEACHING LINE No. of Lines ---_._ ------ Length of each line----____NQS____------- Total Length i 'D' Box _.--------- Type Filter Material -, A<*------Depth Filter Material -----/V--1--------------------------- } Distance to nearest: Well __.... - ----__ Foundation .-._ �1___---- Property Line --- .-----•---------- ' e SEEPAGE PIT Depth _.-_ '--- Diameter - -rr- Number ---- ]_-----___Y-Rock Filled Yes Na i❑ Water Table Depth ----------�� ------Rock Size s �I Foundation ---z�`.------ Prop. Line -- -- ---. Distance to nearest: Well--------------- 1Date ---------------------------------- REPAIR/ADDITION ) (Prev. Sanitation Permit# -------------- ----- ASeptic Tank (Specify Requirements) ---------- ----------------- - Disposal Field (Specify Requirements) -------------- -------------------------------- L,.-�. 1. - ----------------- F ---- ----------- _1.{,-•."', - --------------------------------------------------------------"'--------------------- .-.-- --+ (Draw existing and required addition on reverse side) ,t I hereby certify that 1 have prepared this application and that the work will be done in accordance with San 'Joaquin { f County Ordinances, State Laws, and-Rules and Regulations of the San Joaquin Local Health District. Homeowner or licen- ' sed agents signature certifies the following .� ice^ ,-_ "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 become subject to Workman's Compensation laws of California." Signed ----------------- ------------ --- - ------ ---------------------------------- . ,Owner _ �. �t --------- Title - "' _. (If other than owner) X FOR DEPARTMENT USE ONLY { ----------. DA ---_7 TE -�------------ APPLICATION ACCEPTED BY _--- _- -•.------ - - - -- - - BUILDING PERMIT ISSUED ------------DATE -------------------------------------- ADDITIONAL COMMENTS COMMENTS - -- --------- ---- ---- --- - -- - -- ------- - - - - ----------------------------------- ---------------------- ----------------------------------------------------- s o� ------- ----- -------L --ate------------- ------- -- --- o__by: " ---------Final Ins ectin k� SAN JOAQUIN LOCAL HEALTH DISTRICT k) ' E. H. 9 1-'68 Rev. SM