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FOR OFFICE USES APPLICATION FOR SANITATION PERMIT f z3 t / 0 Permit No `� .. . ................. (Complete in Triplicate! �/ r �: .......... ........................ ;(6 .. ............:..... j f Date issued .C: ?. This Permit Expires 1 Year From i7ote is ' p sued - ..... ................. ............. heroin Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the worts I described. This application is made In compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ... c /ri.....�?�' J....................................... Ci:NSUS T � ...... - Owner's Name . ..................................I......... o e Address /.. .�. - 1 / ..............................._City p-� �..... . ...... ..:.... .... .. ....................License#c?. /.Ch 1.... Phan* Contractor's Name r Installation will servor Residence 0 Apartment House❑ Commercial❑Trailer Court 0 s Motel ❑Other.............................I.............. \ Number of living units,..............Number of bedrooms .5!.....Garbage Grinder ....----.... Lot Size . 160..---•--..... Water Supply: Public System and name ....................•---..._........................_..................................................Private R Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ day Loam 13 -�• ' Hardpan❑ Adobe 10 Fill Material ............If yes-type--------------- ------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed t reverse side.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 204 fee ,l PACKAGE TREATMENT 11: SEPTIC TANK # Size................................................ Liquid Depth ........................ Capacity .................... Type .................... Material...................... No. Compartments ..................... Distance to nearest: Well ....................................Foundation ...................... Prop. Line .................... LEACHING LINE [ j No. of Lines ........................ Length of each line.............•...... . Total Length .................---.....-• t 'D' Box ------ Type Filter Material ....................Depth Filter Material ........................................... t nearest: Wel) Foundation ........................ Property Lins .......................: Distance o ........................ Number >.. Rock Filled Yes ❑ No - SEEPAGE PIT C } Depth Diameter ................ .....--............. WaterTable Depth ................................................Rock Size .,.............................. E `9 Distance to nearest: Well •.......................................Foundation ........ ........... Prop. Line ............... _....... REPAIR/ADDITION(Prev. Sanitation Permit# ... •--- .........-- Date .....;.:�t ............. ••••- ..l . Septic Tank {Specify Requirements) 10 - ...... Disposal Field (Specify Re uirements � •-- 6 .. . . r p ( peC fy q l . o ..................... '..............._................... ..... -• ................................................ versa side) ................................................. ...................I.............................. ........_--•-•-•-----••- .... (Draw existing and required addition on re - 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 iicen- sed agents signature certifies the following: "I certify that In the performance of the work for which this permit is issued, I shall not orn I y anY person In such etalltt!!r as to become subject to Workman's Compensation laws of California." Sign � ....... --•-- ........... ..... ._ Owner` $ � .... .... ................................. Zitle . .(�/G Y (if other t owned FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ........ .-. ..-_-• ... ............. DATE .... "..? .............•.:: ................. ........_.......................... ..•..... -Dart: BUILDING PERMIT ISSUED ADDITIONALCOMMENTS ..............................................................:........................... ...... ................... ... ...._..-................................_.. ...•--•-..-:................--------•••- •.....Date......[?-�fG`16..........._..... . . ... Final Inspection by: ETH 13 24 1-68 ..-5 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M