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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 Local Health District for a permit to construct and-, stall the work herein j described. This application is made in compliance with ounty Ordinance No. 54 a existing Ru s and Regulations: JOB ADDRESS/LOCATION -a- -�:(!��E TRACT --------------•--••------- Owner's Name �r ------- --------------------------------------- --------- ^ ----Ph e ----------------------------•------- P Address ------ Contractor's Name ----- ` Q --/ 1� --------------- - ---License # - Phone . ` Installation will serve: Residence Apartment House[] Commercial ❑Trailer Court I❑ Motel ❑Other Number of living units:.__---- Number of bedrooms ____Garbage Grinder >69!;Lot Size --1 '� � --.--- - f Water Supply: Public System and name -------------------------------•-------------------------------- --------- --------------------------------Private a Character of soil to a depth of 3 feet: Sand b Silt E] Clay ❑ Peat❑ Sandy Loam 0 Clay Loam;❑ Hardpan ❑ Adobe ❑ Fill Mciterial ------------- 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,) J f 1J PACKAGE TREATMENT [ } SEPTIC TANK S-ze_- - _-- Liquid Depth f- -_-_-_ _ ,[ Capacity _"-_ Type fJ Material-ft-, 7 _allo. Compartments ------�:•-:_--.- r Distance to nearest: Well "-�100_/------------------Foundation ------ Prop. Line --__-"""'------ LEACHING LINE Q4 No. of,Lines -------_ _ _ "� � i /�' ''�'- -------- -- Length of each lin ----�--- -------- -- Total Length ��---------_-- 41* -- D' Box l Type Filter Material/ epth. Filter Material _4� _ # Dtance to nearest: Well ------- Property Line. "~"^-"�"' ------------ is SEEPAGE PIT [ ] Depth __9-------___ ___ DiameterNumber -:-- -__-___--1i Rock Filled Yes No 1❑ �j �J Water Tabie Depth -------------------------------- Rock Size - 's-------------------- Distance to nearest: Well --- 1-420------------------- -/ap --- Prop. Line ---_ ------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------.-•__-) i Septic Tank (Specify Requirements) ----------- -- - ----- ---------------------------- -----------------------.--"-------------------------...- - ---------------------•� .. 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 nol employ any person in such manner { as to become subject to Workman's C mpensat' n laws of California." Signed --------- --- -------------- - ---- ------------------------ Owner 8Y Title - 04_1 -------------------------------------- f other than owner) FOR DEPARTMENT LIS ONLY R�ICATION-,ACCEPZF-O—B DATE - --- BUILDING PERMIT ISSUED -------- ---- -------.--------------DATE - ----- ---------------------- ADDITIONAL COMMENTS -------------- ----------------------------------------------------------------------------------------- ---------- --------------------------- - -------------------- ------------------------------------------ --------------------------- --------------------------------------------- --- ----------------------- '------------------ - S--------------- -------=------ Final Inspection by- -----------------------------------------•--------------------------- --------------- ------ -}�v -� --- - Date - --- ----------------------------------- SAN JOAQUIN LOCAL HE T IST RICT E. H. 9 1-'68 Rev. 5M.