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Y FOROFFICE USE: ' APPLICATION FOR SANITATION PERMIT ° ---=---- - ---------- �' (Complete in Triplicate) Permit No: ___74-_________. w -----'--------------- --- !!// ---------------------------------- ---_---------------- This Permit Expires 1 Year From Date Issued Date Issued r-70 r 5 X -2-Z. Applica#ion is hereby madehew to # n Joaquin*Local Health District for a permit to construct and install the work herein described. This application is ade in compliance with County dinance No. 549 and existing Rules and Regulations: ,, r �— i JOB ADDRESS/LOCATION �` ACT Owner's Name Q - � --------1 - Phone ------------------------------------ ---- Address --- ----- = �: `€ FCity ------------------------- Address Contractor s Name _. IAt 6��}--- e1oz/------- ------------------------------------License #11z _ _ Phone -1---r--------------- Installation ----- Installation will serve:; Residence ❑ Apartment House❑ Commercial.XTrailer Court ;0 Motel ❑ Other ------------------------------------------ Number of living units:_/% __ Number of bedrooms/Y�_Garbage Grinder ----- Lot Size �, .0 ------- I WaterSupply: Public System and name -------------------------------------------------------------- - -------------------------------------- -- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;❑ Hardpan ❑ Adobe Fill Material ------------ If yes,type ---------------------------- e (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,j y PACKAGE TREATMENT ( ] SEPTIC TANK(]. Size_� `�`_ t__t'- ---------------- Liquid Depth ___ '_------------- Capacityp-2Q17.0--__,___ Type ___ MaterialNo. Compartments _ __ ________________ Distance to nearest: Well 320____- Foundation l Prop. Line ___rr` ----------- = LEACHING LINE [A— No. of Lines _3____________t _____ Length of each line ____j _�__.._____ Total Length ___L_.S`p__ __.__-_ _( _ �.'D' Box _��.- Type Filter Material �d--��'; ---�____Depth Filter Material f_________ ---------------- i f Distance to nearest: Well _,3a__a__--------- Foundation ___L D_--------------- Property Line_ ..4_`.------------ i SEEPAGE PIT [4----- Depth _._�- �_____ Diameter _3.��f_____ Number .___.3____.___.___ Rock Filled Yes aNo .� Water Table Depth _ZP-4------------------------------------Rock Size _�_ 1, ---------------- -Distance to nearest: Well __3z2_0_----______________________Foundation __/0-____________ Prop. Line --- ......... REPAIR/ADDITION(Prey. Sanitation Permit# --------.------ -----_---------------------- Date ________--________________________) i SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------- ----------------•----------------------------- Disposal Field (Specify Requirements) -------------------------------------- ---------------------------------------------- -------- ----------------------•--------------- ----------------------------------------------------- ------ ------------------- ------------------------- --------------- -------------------------- - - ----= ------------------------------------------------------------------------------------------------------------------- -----------------•- 1. (Draw existing and required addition on reverse side) I hereby certify that I have prep red this application and that the work will be done in accordance with San Joaquin i 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 hof the work for which this permit is issued, I shall not employ any person in such manner as to become subje t W kman's Compensation laws of California." Signed --;T_ -- --------1----------------------------------------------------- Owner BY ------------------------------------------------ --------- -Title ------ ----------------------------------------------------------------- - other than owner) P FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY --- ---- - --- -------- ----------------- ------------------------------------- DATE -----r-M 1Z^-� - - ---------------- BUILDING PERMIT ISSUED --- ------ ---------..:- DATE ADQITIQNAL COMMENTS -Z_' `� ------ t -� -- .k rt e "= - ---------------------------------- } ( ----------------------------------------S---------- ----------------------------------------------------------------------------------------- ----------- -------- -------- -----------•------- Final Inspection bY: ------- --- --- - - --------------------------------------------------------------------._Date _.---- ' a► b j SAN JOAQUIN LOCAL HEALTH DISTRICT S% E. H..9 1-'68 Rev. 5M