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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -13 71-3 1:c � Permit No- -- ------------------ -- ---------------1 - ------------- --------- [Complete in Triplicate} ---------------- ----------------------- --- ------------- Date Issued - - ---------- This Permit Expires 1 Year From Date issued , --------- -------------------------- - ---- Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: j /E -- CENSUS TRACT --------------------- JOB ADDRESS/LOCATION _I =ff ]_-�' -------Phoned Owner's Name -_yy� -------------- `-------- r/L�_ - ']' ' ------------ �i- - '1 ----------------------------------------------------- Address ----- ---------------- Address l�r�1- �---- �- ��----------------------------- City Phone -------.License # y ----------?---------"--/- 's - - 's Name Contractor Installation will serve: Residence Apartment House-E) Commercial :❑Trailer Court i❑ Motel ❑Other -------------------------------------------- living I • Number of bedrooms ------------Garbage Grinder ------------ Lot Size _________________--- -------Private Water Supply: Public System and name --------- ---------- ------------------ -------- -------- - ---------------_----------- -------------- t Peat Sand Loam Clay Loam '❑ I Character of soil to a depth of 3 feet: Sand'❑ Sift❑ Clay ❑ ❑ Y Hardpan ❑ Adobe'❑ Fill Material ------------ If yes, type ---------------------------- etc. must be placed on reverse side.) (Plot plan, showing size of lot, location of system in relation to wells, buildings, NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) TIC TAMC Size___ ------ Capacity Liquid Depth _----------------' 6 �. PACKAGE TREATMENT [ ] [ ] ----- P y`I _ No. Compartments S Ca acct �-- ---- --- -- ---- Typ e ------------------ - Material---- - - Distance lto nearest: W - ------ ------------------- undation ---------------------- Prop. Line ------.--- •--------•- t of each Ii Total Length ------------------- -------- LEACHING LINE [ ] No. of Lines ----------------- g ---•De Depth Filter Material -------------------- V1 D' Box +--------- Type Fie al P t Property Line - 0 ,to nearest: Well -- "-- F undation -_-"------- --------- PDistance DiaNumber _.------------------------- Rock f=illedYes ❑ NoSEEPAGE PizDepth _-------- ---------Rock Size --------------------------------Water Table Depth -- - -�}Distance{i Foundation -------------------- Prop. Line ..-------------------- to neares#: Wel ________1 Date REPAIR/ADDITION(Prey. Sanitation Permit# ___-_-_ .____--------------- q P (Specify q enfis) ------------ ------------------------------------- ------------------------------•---------------------------- } --- Disposal Field (Specify Requirements) - ------ ---------- ------------------- i ;I ------------------- --------------------------------------------------------------- ----- ---- - -- - - ---------------------------- ------------------------ - (Draw existing and required addition on reverse side) r 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 Son.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 tWw orkma Compensatioll law of California." Signed ----------------- Owner Title -------------------------- --------------------------------------------- I (If other an oner) 11F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE ----� ---1 -------------- -------- --------------------------------------- BUILDING PERMIT ISSUED------------------I-- COMMENTS _----------------------------------------------------------------------------------------=------- --------------------------------- --------------------------------- ----------------------------------------------------------------- ---------- __ _ Date --. :~ ---------------------=-------------------------------------------------- -- Final Inspection b -------------------- ------------------------------- - ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M