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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT p --------------------------------------------------------- 4 1-5 _ Permit No. _ c�.--_{�6 (Complete in Triplicate) --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued --- ®5t�— `oa r62- - 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 -------- !/ CENSUS TRACT Owner's N e -------------- - --------- ----- ,,�,�f -------Phone 3--9 - �-e7 --- Address .- -- PZ � City -- V �` Contractor's Name --------- --------- -.License # .�.a �°�� Phone �T_� Installation will serve: Residence ❑Apartmerit House❑ C mme cia �❑ kN Motel XOther Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size IZZ _ ____.- ---------------- Water Supply: Public System and name ---------------------------------------------------------------- ---------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Fa❑ Sandy Loam Clay Loam El Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------- - o (13 {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 ifpu�blic s9wer is available within 200 feet, `` � PACKAGE TREATMENT [ ] SEPTIC TANK -------------------------- ------- Liquid Depth ------ ----------- Capacity 31-to 6 4------__ Type . Material__��.__ ----- No. Compartments ______ ____________ (� ► t Distance to nearest: Well __ _ ___ ---------------Foundation _.. _________ Prop. Line --!-- r i LEACHING LINE D< No. of Lines --------_ ------------- Length of each line---4!9--________.___--- Total Length ____--.a,R 0 _________ 'D' Box ----/---- Type Filter Material _`Sll"_bCMaterial _-____- _______ _.,* leDepth Filter M ____ _____......._,_-_ Distance to Barest: Well _-__'r_ Foundation ______________ Property Line SEEPAGE PIT Depth *-�__._�___ Diameter _ _ ______ Number -_____--------------- ____ Rork Filled Yes ®' No d ' ` Water Table Depth -------- ------------------Rock Size ----------- Distance to nearest: Well 4_d_�. -----------------Foundation __._. -- Prop. Line ____ _ _,_ � REPAIR/ADDITION(Prey. Sanitation Permit# __- --------------------------------- Date _.______._________-___-_________-1 Septic Tank (Specify Requirements) ------------------- - t ---------------------------------- ----------------------------.- ------ Disposal Field (Specify Requirements) ------------ -------------------------------------------------------------- -------------------------------------------------------------------------------------------------- -------------------------------------------------------------- ----- ------------------------------------ (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: d "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 bec a su [ect,to WorkAn's Compensation laws of California." Signed -------- --------- ------ -- ------------�-- -- —----------- Owner r ' By --------------- ------- -----------"--- "/!f4 * .�------- Title --- ----- - (If other than owner FOR DEPART USE ONLY t' APPLICATION ACCEPTED BY ..... ---- ------------ ----------- ----------- DATE --- ---------------- BUILDING PERMIT ISSUED ------------------- ---------------------DATE __.------------------- - ----- ----- - - ------- ---- --- -- ----�-------- ------------------=-- ADDITIONALCOMMENTS --- --------------------------------------------------------------------------------------------------------------------------------------------------------- 1 -- Y --- ------------------- -_ _,___ -- -------------- -----------------------Ye- --- -- -------------------------------------------------------------------- ------ ------------------------------ ------------ Final Inspection by: -- -- _- -- _-- Date --.-'".7._"p��---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M 1