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FOR OFFICE USE: ^� APPLICATION FOR SANITATION PERMIT �a (Complete in Triplicate) Permit No. --------------------- - - - ---------- This Permit Expires 1 Year From Date Issued Date Issued __ _-_-------�� 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 a fisting Rules and Regulations: JOB ADDRESS/LOCATION .__..-L_.c-S ---. ----------- -- - -- - ----------- --� --- ----�S TRACT -------------- ----------- Owner's Name -__ - � - ----- --------- Phone Address 1_ --- ---- --------- --------- City _Al2 --------------------------------------- --- -- Contractor's Name ___-- --- - - --------- ---------License # cz G_�l/j 'Phone - r� Installation will serve: ResidenceApartment House /commercial ❑Trailer Court ',❑ Motel F] Other -------------<fe� --k`--------------- Number of living units:...,___ Number of bedr ms _____/__ Garbage Grinder !--Q Lot Size _A!�;_a_P_-___- - Water Supply: Public System and name ---------- - ---------------------.------ ---------------------------_-----.-----------Private ❑ Character of soil to a depth of 3 feet: Sand'[] Silt❑ Gay ❑ Peat❑ Sandy Loam '❑ Clay Loam ' Hardpan ❑ Adobe ❑ 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 side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet \ ,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ],�� 1 S1'ize------------------------------------------------ Liquid Depth -------------------------- 1 Capacity ----------- -------- Type -------------------- Material---------------------- No. Compartments ------------ ......... V Distance to nearest: Well ___________________________________Foundation .._.__._____________- Prop. Line --------- ....... (�1 LEACHING LINE No. of Lines __ _. - Length of each line_____ _-_a _ Total --- -- '�-------- -- Length -----lam-ftp- ------------- 'D' Box -t1V_ Type Filter Material _A ----Depth Filter Material ___/1*1:1------ _______________________ Distance to nearest: Well ---ls_41�1---------- Foundation --__`Z17----------- Property Line -----�__________-_•-__ SEEPAGE PIT Depth Diameter lNumber ------------ Rock Filled Yes No ❑ Water Table Depth ------46011,00--------------------------------Rock Size ----C7------ ----------------- _ Distance to nearest: Well r..�- _4'---�._____-___.Foundation ...`a_._F___ Prop. Line ....__ __._._ __.. REPAIR/ADDITION(Prev. Sanitation Permit# -___--__-____________________ ___ Date _________-__________________-_____) Septic Tank (Specify Requirements) ------- -------------�Q 1 ---------------- 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: "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 become subject to Workman's Compen3ati.on laws of California." Signed ------------------------ Owner BY Title ---------- -- ---- �l (If other than owner) ./ FOR DEPARTM T USE ONLY 9L APPLICATION ACCEPTED BY ---�---- --------<- --- --------------------------------------------- -------------- DATE --- `�1 -----77- -------------- BUILDING PERMIT ISSUED --------- ------------------ ------ --------------DATE ------------------------------------------ ADDITIONAL COMMENTS ------------------------------------------------------- ---------------- ----- - ---------------------------------------------------------------------------------------------- - ---------------------- - / - -------- -- Final Inspection by: ----- --- -------------------- -----Date ----- - ---- = SAN JOAQUI ' LOCAL HEALTH DISTRICT -- -- �/ �'E. H: 9, 1-'68 Rev. 5M