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0(03 -170 -�� FOR OFFICE USE: "" APPLICATION FOR SANITATION PERMIT / Permit No. ------------------------ -------- ------------- N. {Complete in Triplicate} . I Date Issued This Permit Expires 1 Year From Date issued ---------------------------- ---------------------- ------ Application is hereby made to the Saijoaquin oca ealth 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: f t IL `f '�' �ld�/----------------------CENSUS TRACT JOB ADDRESS/LOC O - -F �` Owner's Name __. QC�� s.d [ --------- -------Phone ' � --------------------------------- Address ---- 1�/_�C'------ C�. City Contractor's Name -�-1� ! u --- --�-._��- - -�-�`--'�-- S-� �!�'--��/-�--/-4t".1r1 ----License # ---- d P�-- Phone --------- - Installation will serve: Res idericeVApartment House❑ Commercial :❑Trailer Court i❑ < Motel ❑Other -------�-------------------------- ---- Number of living units:_____1_____ Number of bedrooms -_->2__-Garbage Grinder ---— Lot Size ---------------------- Water Supply: Public System and name ------------------ - - ---------------- -------.-------•---------------------------Private, ' Character of soil to a depth of 3 feet Sand'❑ Silt❑ Ckay .❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ s - Hardpan ] e 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.) .11 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) -� s PACKAGE TREATMENT [ SEPTIC TANK:[4 Size__.__-��}_- ,-s� ----i - ---- -- Liquid Depth ___ --_- •---,---,- rt Capacity J` I!V------- Type - -,--------- Material_L ,at4YeVe No. Compartments -----�---------.-- Distance to nearest: Well -----�0__ __---------------Foundation __lam` -______----_-.Prop. Line ._____.a_P..-.... LEACHING LINE Q6' No. of Lines ------- ----------- Length of each line_.__----�04 _0 ----- Tota) Length - ---------- 'D' ---------- 'D' Box __j_:____ Type Filter Material -----A__-/-----Depth Filter Material.-------/__ ___-----------•__---_ ------_--.- Distance to neatest: Well __s5_A------------- Foundation ---le--------------- Property Line ------------------ 01 -- -------------- .r SEEPAGE PIT (] Depth Diameter Number -______- Rock Filled Yes ® No 0 Water Table Depth ---------- 1------------------------- ------Rock Size ---------�-----i-,----------- ' Distance to nearest: well .______/aD-----------------------Foundation ---/4_1! Prop. Line ____--- i REPAIR/ADDITION(Prev. Sanitation IPermit# -------------------------------------------- Date ----------------------------------I Septic Tank (Specify Requirements) --------- � ------ j - ------------ - - - 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 Compensation laws of California." Signed ------- - ------------_--------------s-------------- Owner B ---- --- -- Title .. (If other than owner) FOR .DEP NT USE ONLY APPLICATION ACCEPTED BY t -- --- -- ---- DATE g .t 7/ BUILDING PERMIT ISSUED ------------}-------------------------- --------------------- --------------------------- DATE ADDITIONAL COMMENTS ----------; - ------------------------------------------------- -------------- vi�--------- �.t ------------------------------------------- ------------- ---------- - -------------------------------------------------------------------------------------- `--------------------------------------------------------------------------------------------- - i ______________________________________ _ ______ ____ 4 Final Inspection b Date - -'-1_ - --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M