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v FOR OFF[CE USE: APPLICATION FOR SANITATION PERMIT ........�.--•-•........................................ Permit No. ....... .---._... T y a (Complete in Triplicate) ...................................................... .......................... ................ 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 install the work herein described. This application is made in compliance wit County--Ordinance N01-549, d existing Rules and Regulations: DROT E ACT .......JOB ADB ...._._....•....... Owner's Name .............. :... ....Phone .................................---• I Address .c ,. - ... __. !'� "-� "`f ..._. City ._.._ . Contractor's Namel.....- :.. .. License /� .��Phone .. �a a Installation will serve:- Residence partment House Commercial (]Trailer Court ❑- -_ . 1 i Motel ❑Other .........................I..........___..... ' Number of living units:._.._._(___ Number of bedrooms-.._..__._Garbage Grinder --.:Lot Siz ., ", .. Water Supply: Public System and name --- - - - Private Character of soil to a depth of 3 feet: Sand Z] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam .� Hardpan ❑ AdobeFill 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,) PACKAGE TREATMENT SEPTIC TANK'I j Size...............__............................... Liquid Depth .......................... Capacity ....-- •........ Type .................... Material----- ................ No. Compartments ...................... Distance to nearest: Well ....................................Foundation....................... Prop. Line ......................6 LEACHING LINE [ No. of Lines .................."__... Length of each line.----.- .-._. .. Total Length .............. V - - D' Box Type Filter Material ...•_.Depth Filter Material - - � Distance to nearest: Well ........................ Foundation -------"._.--------.:_._ Property Line.......................... SEEPAGE PIT [ ) Depth Diameter ________________ Number ............................ Rock Filled. Yes ❑ No �❑ ' d_ .-Water.-Table-Depth ............. Rock Size Distance to nearest: Well --------------------- ...........Foundation ------------ Prop. Line ................ REPAIR/ADDITION(Prev. Sanitation Permit# ...........................-........... Date .....................__...........) Septic Tank (Specify Requirements) ---------------------- ........53�--l-----• ... ........ ._..........._..:._^ _ -�.......Sr`._._ Disposal .F�ld (Specify Re`gvirements) ------------••C��-� -----•7 .-.�..- --------- - -------------- ... ---•-------._.--�-- •- -�#� t J ............................... ---"-.-------------•-•----................._..................................................... ..................... (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 Son 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: "1 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 J By -------- -- Title ...... ........ -- "-- ..... .. (If of r t o ner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...._.._ --- - - -- ----------•--•--.....------"---------._.....: ....................... DATE ...... ..�!�...�¢......._..... BUILDING PERMIT ISSUED ........ 4- _ DATE ........................................... ADDITIONAL COMMENTS _.'- . ...... ...................•-•--••••••-----......."•••--••. ..............•......--• ..... .................................................... ___._..._..----•-..........._..------•... ......-•-------•---•-----••-•- ......... i ------------ .. ----------------- .............................. ,. .......... .... Final inspection by -- . .................. Date ........ . SAN JOAQUIN LOCAL HEALTH DISTRICT r u 13 24 t.,Ajt ap,._ sm 7/72 3 114 ,i