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FOR OFFICE USE: APPLICATION FOP- SANITATION PERMIT -------------------------- (C+;mpfete in Triplicate)` Permit --------------- ------------------------------------------- Date Issued ____�_.___-- This Permit Expires 1 Year From bate Issued • i 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 with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION ---9- --- LG/ �I/f/�C---- .....Q '.------------------------------CENSUS TRACT ---------------------•---- Owner's Name -----130-5---------1 Fl.�_ -------------•-------- ------ -----------Phone.--7 Address ----------5AW --- Contractor's Name Y 1 -------•-_-------.License # l .t.�5 7---- Phone Installation will serve: I Residence X Apartment House❑ Commercial : Trailer Court ❑ i Motel ❑Other Number of living units.--J------ Number of bedrooms _)------Garbage Grinder " ------- Lot SizeId_/ i�G' - --- ------------------- Water Supply: Public System and name ----------------------.---------- Private ----------------•----------------------------- Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Ciay Loam 0 Hardpan ❑ Adobe'❑ Fill Material ------------ If yes, type ------------------_-_____ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must he placed on-,everse side.) k NEW INSTALLATION: ( No septic tank or seepage pit permitted if public sewer is available within 200 feet, -.r PACKAGE TREATMENT 11 SEPTIC TANK t4 k Size._17)(5_ x'�--�--�-----•--- -- --- Liquid Depth`. --------------_-- Capacity -------------- - -•Ca acit 1041--- Type/W ✓ MaterialCNo. Compartmen'ts f c-_.---_:_.••_:._- Q; Distance to nearest: Well -,,V1-r ------ Foundation ----------- ------- -------------- -h`___- P• Line �Pro __ � LEACHING LINE ) No. of Lines :------ ------- - --- Length"of'each lin'e_M '- -- flfaI- Length /" d_/--•------------ a D' Box N.,Q---- Type Filter Material :----Depth Filter, Material -__-- f-Di•stance to nearest: Well � �---- ----- �j- Foundation 10-----------------;;Pioperty Line �' -----------=-•-- SEEPAGE PIT Depth -_ - Diameter _ -Rock Filled Yes No i❑ [� E �� ' ;Number ------------------- - Water Table 'Depth ----___Zy-E9�---------------------------Rock Size - - Distance to nearest: Well ---1,M----------_-----------------Foundation ------------- Prop. Line m7— _-_- REPAIR/ADDITION(Prev..Sanitation Permit# -------•------------------------------------ Date -------------_ ) ' Septic Tank (Specify Requirements) ---- --------------------------------------------------- Disposal -------------------- __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 not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------- ------------- - ----- --- -- --- ----- ------ -------------------- Owner BY --- - -- -- - -------------------------------------- Title �6� I (!f Cher th owner) -- --- --------------------------- FOR DEPARTMENT US ONLY APPLICATION ACCEPTED BY -- DATE _--- ✓-_---- '� _-- ----- - - -------------------- BUlLDING PERMIT ISSUED --__-_ _------- DATE -__-_-- ---------------------- ------------------ ADD ITIONAL COMMENTS ------------------ - --------------- --- -----•='�--"---•---- ------------ - - - � -- . ------------------------------------------------------ - ------------------------------------------------------------ -- ----------------------------------------------------------- ----- ---------------------------------------- f Final inspection by: ------ --- - --------- ---- ------ - ---- -_ - - - ------------.Date -- -- ---! SAN JOAQU LOCAL HEALTH DISTRICT I E. H. 9 1-'68 Rev. 5M