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FOR,OFFICE USE: APPLICATION FOR SANITATION PERMIT f Per (Complete in Triplicate) a rryt No. _ Z:?------- 14 r�_ This Permit Expires 1 Year From Date Issued Date Issued _�'Z- .:.�.Z -----------------------___-------------- 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: JOB ADDRESS/LOCAT N ---;� 3------- k -----�----------------------�----------------------CENSUS TRACT -------------- ........... Owner's Name C++ '------ ------------------Phone -_!649- .3!el...--- Address -----------------�. �; � - -------------- City - ------------------------------------------------- _V --- Name ______--_1________________,_____ ____0___S_B'� ------------------------License #16k3W_________ Phone �6"7ov.... Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court !❑ Motel ❑Other -------------------------------------------- y Number of living units:_________ Number of bedrooms __y._.Garbage Grind ------____ Lot Size ---�b----_x_J_---------------- Water Supply: Public System and name -----------------------------------------------------------1 -------------------------_-Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ 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,) "1 PACKAGE TREATMENT [ ] SEPTIC TANK', ize____ q p t ------ -- Liquid Depth 1-► ,�� 12— Capacity �,. �}�l 4)* Type __ Material___ No. Compartments Distance to nearest: Well _________________________________--Foundation _______ Prop. Line ._._........__.__._ P LEACHING LINE No. of Lines _______/--------------- Length ofeacpph line---lFQ__ _� ______-______ Total Length , VQ................ �� 'D' Box ------------ Type Filter Material _F-J_tC 2______Depth Filter Material _____--/ ----------------------------- Distance to nearest: Well ________________________ Foundation ____l0_______________ Property Line __ ................ SEEPAGE PIT ] Depth ______ Diameter `_53_"_____ Number ----------/--------------- Rock Filled Yes No i❑ / .r Water Table Depth ------------------------------------------------Rock Size --�-/-J-=---------------------- Distance to nearest: Well----------------------------------------Foundation ------- Prop. Line _ _.. ............ REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ________-.-•-_-___--_______-----__) SepticTank (Specify Requirements) ------------------------------------------------------------ ---------------------------------------------- ------------------------------ DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------- ----------------------- ------------------------------------------- -- --------- ------------------------------------------------------------------------ (Draw existing and required addition on reverse side) 1 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. 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 ---------------------- Owner BY ---------- 1 ------------------------------------ Title ------ ----------------------------- -------------------- (If oth han owner) FOR DEPARTMENT US ONLY �r APPLICATION ACCEPTED BY -- ----- -- ------------------------------------- DATE #� � BUILDING PERMIT ISSUED ----------------------------------------------------------- -------- ------- ------------------------------ ---------------------------------------------DATE ------------- ----------------------------- ADDITIONALCOMMENTS ------------------------------------------------------------------------------------- ------ ----------------- ----------------------------------------------- ----------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- --------- - ------------------------------------------------------------ -------------------------------- ------ --------------------'------ ---- --------------- --------------- - --- -------- - Final Inspection by: - ------- -- --- ------- .--- - ----- -------------------Date } SAN JOAQUIN CAL HEALTH DISTRICT -) E. H. 9 1-'68 Rev. 5