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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- ----- �---- -------- --•----- ------- ��--��,�..� {Complete in Triplicate} Permit No: ----------------------------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin I�Local Health District for a permit to construct and install the work herein . described. This application is made in complia hce with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS LOCATION -_ I CENSUS TRACT Owner's Name ------- ' -*-- I Phone t Address - _� -__ i ---------------------- City 'r' 'r" -----------------------------------------•---•-- Contractor's /1 me ---�",L----------------------- I�--------- License # Phone Installation will serve: Residences A artment House,0 Commercial :[]Trailer Court i❑ Motel ❑ Other -------------------------------------- ---- Number of living units:---I------- Number of bedrooms -%f--------Garbage Grinder --- __ Lot Size ts4-------------------------- Water Supply: Public System and name ------------- -----------------------------------------------------------------------------------Private MR Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .❑ Clay Loam V Hardpan Adobe ❑ Fill Material --------- -- If yes, type ---------------------------- (Plot plan, showing size of lot, location of sysltem 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 [ I SEPTIC TANK'W] } q p Size --- - :t-------------- -- Liquid Depth �L---.-•-------- .. Capacityb; .6-a-------- )(pe _t4q---------- Material------------- ------ No. Compartments ---2- 1 Distance to nearest: Well ...-f_6`8 -----------------------Foundation ..-1- -___-------- Prop. Line _ S____- -----.-.-.- LEACHING LINE No. of Lines - Length of each line____ --10-d___________ g .g_ _______________ Q 1 I� g Total Length 'D' Box W` ._ Type Fii -lter Material ----------Depth Filter Material --.1 -_`- ------------------------------- Distance to nearest: Well -- A0------------- Foundation 10 Property Line - r --._-.-_...._. Ar SEEPAGE PIT 5A Depth _5------ ----_ Diameter -3-3--------- Number _.___ _________________ Rock Filled Yes ] No I❑ Water Table Depth I�-----------------------------------------Rock Size --------------------------------- Distance ------ ------------------------ Distance to nearest: Well..----------------------------------------Found .. ation ---------------.---- Prop. Line -------------- ------ REPAIR./ADDITION(Prev. Sanitation'Permit# -----I�--_ Date ---------------------------------- SepticTank (Specify Requirements) -----------------I=----------------------------------------------------------••- --------------------------------•------------------------•-- V.; Disposal Field {Specify Requirements) -------- 1"�---------------------------------------------------------------------------- -------------------------------------------- , --------------- --------------------------------------------------------------I------------------------------------------------- - - --------------------------------------------------------------------- ------------I---------------------------- 11 (Draw existirib and required addition on reverse side) I hereby certify that 1 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. Nome 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 Compensation laws of California." Signed _ e,. ------ Owner BY ---------- ----------1`------------ ------- -Title --------- -- I (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ___._ c- -- -=--- - ---- -- -------•------ --------- ---- ----------------, DATE f�_:� ---------------------- BUILDINGPERMIT ISSUED -----------------------------------.-11------------------------------------------------------- --------------DATE ------------------------------------------- ADDITIONAL COMMENTS -(. -------------- J Final Ins ectio pb - - 'y -------- --- lDate -- Z.t SAN JOA QUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M i