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FOR OFFICE`USEw APPLICATION FOR SANITATION PERMIT - ------- --------------- ---- (Complete in Triplicate) Permit No. ---------- This Permit Expires 1 Year From Date Issued a. Date Issued ---- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein I described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: w C^_ -. ��lrt -� I�C� --------._CENSUS TRACT __5_/ JOB ADDRESS/LOCATION . V------ �4. 7_/-1-._l1 ----- - -- Owner's Name ------ �� I Lhf ---------------------------------------------------Phone ------------------------------------ Address ------ ------------- - - �- -- ----- City /�1-1�!_ .1`4+ --------- Contractor's Name 674,;___I`--------------------------License # --------- ----- - ---- phone 7----------- Installation --- ~Installation will serve: Residence ❑ Apartment House❑ Com ercial :❑Trailer Court 0Motel E]OtherT25W0_ _Number of of living units:---- ------- Number of bedrooms ------------Garbage Grinder ------------ Lot Sizey�� -------------I------ Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private1] Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ • Sandy Loam 'e-1-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 seepag it permitted if public sewer is available within 200 feet,] . PACKAGE TREATMENT SEPTIC TANK' Size__ __ , 1 [ l -------�� d--- Liquid Depth --��-------.----� N Capacity __/)oa --- TYPeIv------------------- Material- �� No. Compartments -------- ----------- 6 �i istance to nearest: Well __-�0-1---- _________Foundation _.l_L'____________ Prop. Line __ __.__.__--_,------ LEACHING LINE No. of Lines -----2:Z------------- Length W<4 ach,line_____-76,__.__.------- Total Length /_91_0------ ------- 'D' Box ----_-----__ Type Filter Material �___Depth Filter Material _1_�____________________ff 6— j Distance to nearest: Well ___ ___________ Foundation -__�_Q Property Line _ ______________ I SEEPAGE PIT [ ] Depth _ --- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 Water Table Depth ----------------------------------- Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation --------------------- Prop. Line -.--_____-________-.-_ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ____________________.___-_____-_-.) SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------- --•--------------------------- Disposal Field (Specify Requirements) -------------- ----------------------------------------------------------------------------------------------------------•----------- ----------- ---- ------------ '---------------------------------------------------------------------------------------------- --1--- ------------------------------------------------------------------- -------------------- ------------------ --- -------------------------------------------------------- ----------------------------------------------------------------------------------------------------- (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- -[ 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 i_-- Owner --------- ---------- /. BY ----- --- �,.�/�.- �--- --------- - -- -�1---------------------------------- Title ----- --------------- ---------------- � (If other than owne FOR DEPARTMENT USE ONLY � 9 APPLICATION ACCEPTED BY -----�iRvwO----= ----------------------------------------------------------. DATE ---- '��` -------- BUILDING -- --.BUILDING PERMIT ISSUED ------- ---------- --------------- --------------DATE ----------------------------- ---------------------------------- COMMENTS --------------------- ----------------------------------------- -------- ----------------------- - -- ---- --- - - -------------------------------------------------------------------------------- --------------------- ------------- - - -- ------------------------------------------- ------------ - -- Final Inspection : _____ - -- � ---------------------------------------Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M