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FOR OFFICE USE: APPLICATION FOR SANITATION PERMITA// (Complete In Triplicate) Permit No. .._.1_.` ... ....................................•--.._.._._.._.... ........................................................ This Permit Expires 1 Year From Date Issued Date Issued . `. ..7 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.. JOB ADDRESS/LOCATION .�....l�i .�.�?.....................•---..�/��>..��'��....................CENSLJ5 TRACT --•-t Owner's Name ....... A...!_ ..._ .. ...........................................................:.............---....Phone -- -- _..0.......... A 3 Address y ,. Contractor's Name ....... �,..............................................License # Installation will serve: Residence to Apartment House❑ Commercial []Trailer Court 0 Motel ❑Other .................. ................. Number of living units:.._ ..______ Number of bedrooms -. __.Garbage Grinder'....._..__.. 'Lot Size ......:..................................... Water Supply; Public System and name .....................................Private Character of soil to a depth of 3 feet: Sand❑ Silt[]1-4 Clay❑ Peat❑ Sandy Loam 0 Cloy Loam Hardpan Q�Adobe -0 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 rsidej 1 NEW INSTALLATION: I (Nonseptic tank or seeps Npit permitted if public sewer is available within 200 feet,) PACKAGE'CREATMI?N {1 SEPTIC TANK � - Size___.Tx. i�.',i�r................... Liquid Depth ---. f -•`.•_.--__ . 'H Capacity r;P!70_ -._- Type ... No. Compartments r r- � i�.�.__�u3.�.�.. Material.........-•-•--•-•- --c�.............. 6 !stance to nearest: Well f 0 4 - ----•...._...__..Foundatio; �A.. Prop. Line ..:........ O LEACHING LINE No. of Lines _..�--------------- Length of each line.._._.P;9..._..._.__.... Total Length ..�1O....!....... 'D' Box ------1---- Type Filter Material 11AXI.-A.Depth Filter N oterial .....eY.I................. .. .•. Distance to nearest; Well -__l ,Q............. Foundation .. �..v....... ... Pro a Line ...... p rty SEEPAGE'PIT IDepth .._........ •---..__ Diameter --•--------..... Number .........: . .....• . Rock Filled Y eso No ' � r Water Table Depth ......................... •...............Rock Size ; ' Distance to nearest: Well ........................................ .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ........................................... Date ..................................I R Septic Tank (Specify Re uirements)l.... .......................................... Disposal Field (Specify Requirements) ....:...........3 fA r -------------•--•-•----............................................... ......._..---........--•-•------............................. ................................................................... ..................I--------- ---.-_._................._.._.. __....`.`.`_.................._.._..._._........_.......................,.:..............:......-....__.........._._._...........:__._......... - (Draw 69isting 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,I State Laws,sand-Rules�and..Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies thelollowing:• t , I "I certify that in the`:performance of the work for which this permit is issued, 1 shall not employ any person In such manner as to become sublet o rkm F ' Compensatian laws of California." ` Signed i - ...... Owner I . Title By ........... ........ ......I.__........ .. ..............---..._.........---------••---- ........ ..............................-........... (If othir than owner) , t FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY .... DATE .._.,.?:..t :..7 ............. BUILDING--PERMIT.-ISSUED- DATE --- -- - i- ADDITIONALCOMMENTS ...........................�... .. ............................................................ •_.... ........... - � .,..,.,. ... -------- -------• -•-• .... • _........._ ....................._..:.;.............._..................... .................... . . .. ---. ................. r.. Final Inspect! .............Date . -` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.1.3 24 1-'68 Rev. 5M �� ___ 7/72 3 M