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t FOR OFFICE USE: APPLICATION FOR SANITATION PtRMI (Complete in Triplicate) -- ---------- Permit No: - # ------ _ Date Issued ------------------------------------.--_ -_---- This Permit Expires 1 Year From pate Issued � i 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 wit County Or finance No. 549 and existing. Rules and Regulations: i JOB ADDRESS/LOCAT N ._-/- ------ - - ) -- ---------------------CENSUS TRACT Owner's Name + - - ---- ---Phone // - Address /_ ��'r� 5k - - - ------- City - - I- G Contractor's Name ._--- t----.License # -/� - Phone ----------------------•-•_---- Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court IQ s > Motel ❑ Other ----------------- ------------------- -- Number of living units:------1.--- Number of,bedrooms-3------Garb age Grinder ------------ Lot Size ------------- - Water Supply: Public System and name __-A------------------------------- ---------------- ----•------------------ - - Private - - ------------ -- - - Character of soil to a depth df-3-feet: Sand'E] Silf❑ Gay ❑ Peat❑ Sandy Loam Clay Loam M Hardpan ❑ Adobe .0 Fill Material ------------ If yes, type ------------------- 1Plot 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;) PACKAGE TREATMENT { 7 SEPTIC TANK[ ] _ Size------------------------------------------------ Liquid Depth -'----------------'_•--_---- L Capacity P Y } :,T�YPe ------ Material---------------------- No. Compartments ----------------------- Distance -----•--Ditante to nearest: Well ------------------------------------Foundation -=-- '--------- Prop. Line ----------- LEACHING ------- —LEACHING LINE [ ] ,� No. of Lines ____1----.� _____________Length of each line4k-�s-_:_-"_==>-__- �Totai Length ------------- J _ -•-------- D''8oz --_""""`�`TYpe Filter Material--_" Depth Filter Material ------------------- Distance __------- ,-Distance to nearest: Well --------------------- -- Foundation ------------------------ Property Line :---------- -----•___-- SEEPAGE PIT [ j Depth -------------------- Diameter ---------------- Number ___-_-.--:____-------_ -____ Rock Filled Yes ❑yfNo 0 # f Water Table Depth ------------------------------------------------Rock Size --------------------- •-•- Distance to nearest: Well -----------------__-----------------___Foundation -------------------- Prop. Line .... _.--....._--- REPAIRfADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------- ) If Septic Tank {Specify Requirements) ------------------------------------------------------ + ' -------------------------- Disposal Field (Speck Requirements) ...... -!?� f-I ------- ---- -- ---- ----------- X S 1----- ----------------=------------------ (Draw existing and required addition on reverse side) 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 beco bject to Workman's Compensation laws of California." Signed _..-_ t Owner BY -------------------- Titlep a (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --------------------------------------------------------- DATE BUILDING PERMIT ISSUED -------------------- ----------- -----------DATE ------------- --------- ADDITION AL COMMENTS ----- - ------- ----- -- ------------ --'--==----------- --- -- - -------------------------------- _ - �-•• � Final Inspection b -- ------- ------p Y - -------------------------------------------------------------Date "rJ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev, 5M