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FOR OFFICE USE- 9_-_% r--- APPLICATION FOR SANITATION PERMIT ----------------------------------- ------------- (Complete in Triplicate) Permit No. ------ ------- ----- This Permit Expires i Year From Date Issued 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: JOB ADDRESS/LOC-_ATIONil--_ _ _ .---, -----umffo�------RD---------------------------------CENSUS TRACT _-J_'_.5`� ........ Owner's Name --- --->_''_ .P�Iuc_�.. - ----------Phone.. _'_ �fg�------ Address ---- FJr i '- ---------UA1.1-Al-- -R0--------4-----------•--- City -- - #q -=-------------- ----------------------------•------ AA Contractor's Name License # Phone S _`_ - Installation will serve: Residence ❑Apartment House[] Commercial ❑Trailer-Gets !,@_ Motel ❑ Other ------------------------------------ F Number of living un s:____ ---_ Number of bedrooms _-4------.Garbage Grinder VO.- Lot Size _ CR9A_67�---__-.____ Water Supply: Public`System and name ------------------------•------------------------ -__,ff1---------------------------------------------Private Ej Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ 4 Sandy Loam -W110"Ciay Loam:E] 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 seeps _pit_permitted if public sewer is available within 200 feet,) t r , PACKAGE TREATMENT ['� SEPTIC TANK [ ;_ Size_____- ___ _�__ _:__K_-_S--------- Liquid Depth -----/--�_________: Capacity _t_ d- .,-_ Type E-TW�k Material 12--ef 12 —No. Compartments _________ .. n Distance to nearest: Well ''{ Q ° "f"`---------Fo' elation _� ___"1`___��Prop. Line '�_____ r LEACHING LINE [ No. of Lines ____._ _�__ Length of each line---_--,a�-.___r_.____._ Total Length _____[ 'C _.___.____ I• �: s , pf q t [ 1 -'Did Box ��"� Type Filter-Matenal _�Q_�__Depth Filter Material Distance to nearest: Well ___SDI----- __ Foundation Property Line, --S___.____________, }I SEEPAGE PIT [ ] k Depth ----------- -------- -D.iar-` etertt'`t___ s:_K__ Number _;._�-#-------------__',____ Rock Filled Yes E] No 0 Water Table Depth _________4__- ' f t r Rock Size . Distance to nearest: Well __ _��___________4_1-- Foundation- - _ _ -! Prop. Line ___________________ REPAIR/ADDITION[Prey. 'Sanitation Permit# ........ 4 --------- Date ------------------------------- --1 fire Tank (S uirements) ----- rt ---- 5e (Specify --------- p --------p p Y Re q --------------- ---{---------------- Disposal Field (Spiecify�Rei rerrentsl - =- - _- �"'- - -------------- ---------------------------------- ---------------------t----------------- - ----------- _ (Draw existing and required iddit0 on reverse side) l I hereby certify that I have prepared this application and that the work willi,be done in accordance with San Joaquin County Ordinances, State Laws, and Rules an°d Regulations of the San JoaquitriLocal Health District. Home owner or licen- sed agents signature certifies the following: ) - "I certify th t in the perfo ante of the work'for which this permit is issued, I shall not employ any person in such manner ' 1.•. r i x ' i as to bet s I t oto o an s Compensation laws of California." i t.i to Signed . -- ------ -i = - 1 -----�'- -- Signed I t - BY ' ti' Title (If other than owner); , li ;FOR QEPARTMENT-a-'USIE'.'aNLY i n APPLICATION ACCEPTED BY ----------� —• -------.---r----.----------------------- ------------i DATE _5 -�- BUILDING`PERMIT-ISSUED-w.ti_._ --._.,�,..,,,-- � ----- =__ � �DE=_-:-!-- "" -` - -- ----- -------------------------------------------------------------------------------- ------ ADDITIONAL COMMENTS -------- ------ ` -------------------------- -- -------------w-----------------� ------------- - --------------------- ---------- ---- - - ----- - - _ � - ..................... ----------------------------------- --- --------------------------- ------- ------ ------- ------ -- --- - --- -- Finallnr----------------------------- Date -------- --- - '` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M '