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FOR OFFICE USE: APPLICATION ICOR SANITATION PERMIT (Complete in Triplicate) Permit No. ..7..s.`....��.. .. ...... 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 with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/L ON ...ar~ _`��....... �v ................................CENSUS TRACT ..............I........... Owner's Name ..- _-. f_. . .__ ............Phone Address . ........ - ��/� ity Contractor's Na = ....... .......License # Phone Installation will serve: Resident Apartment House f] Commercial {]frailer Court l Motel ❑Other ............................ Number of living units:---!....... Number of bedrooms G rbd a Grinder . Lot Size Water Supply: Public System and name ............... .....Private - . ...............................-•---------_...---•---•---,....----..........._... ...... � Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay 0 Peat❑ Sandy Loam Clay Loam ❑ Hardpan 0 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 seepage pit permitted If public sewer is available within 200 feet,} PACKAGE TREATMENT [ ) SEPTIC TANK f ] r. Size............... ......................... Liquid Depth .............. Capacity -------------------• Type ........... Material--- -------..._ ___.... No. Compartments ...-.................- Distance to nearest: Well ...................a_..............Foundation ..____... ....... Prop. Line ......................5 LEACHING LINE ( } No. of Lines ------------------------ Length of each line................ Total length t`i ........................... x., 'D' Box _........... Type Filter Material ....................Depth Filter Material ............................................ rn Distance to nearest: Well .........`_._......_.._. Foundation ................_._..,. Property Line ................. ••----• SEEPAGE PIT ( l Depth -------------------- Diameter ---------------- Number _.__...-------._...__...__.. Rock Filled Yes ❑ No ❑ . Water Table Depth .... ................. - --_----------_----Rock Size ._......- ••----- ...... 6 w 6 Distance to nearest: Well-----------------------------------------Foundation ---___. ............ Prop. Line .................. REPAIR/ADDITION(Prev. Sanitation Permit ,...:--'-------------- ------------------ Date .......... ................... 5' ; Septic Tank {Specify Requirements) ......................•--•--............................................. ti Disposal FieldSpecify Requirements) -� -�_- •----- - --- -•-- r Jam, .... ----------------- •-•-------- ----------_------ ----------------- ........................ .................... (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'.-Ilales and Regulations of the San Joaquin Local Health,District. Home owner or licen- 4 sed agents signature certa les the following: "I certify that in the performance of the work for which thisermit is issued 1 shall not P employ p y an y person in such manner as to become subject to Workman's Compensation laws of California." Signed -------------•--• ---------------- ----- .._' ---------- Owne4" ;Z By ---• •---- ------ -------------- L�lr - Title - (If other than owner) .............. ............................... FOR DEPARTMENT USE ONLYoc + APPLICATION ACCEPTED BY ------ --- _ . 7J ---. ------- ---.- DATE :BUILDING PERMIT ISSUED _-------.------••------- =-. - ---------------------------- DATE ---......_._...__. . -_......ADDITIONAL COMMENTS ..-----. ------ ----- a ; --- ------------- -------- --------•--------- ------L------ ---------------------------•..__-------. ---------- - -------------..-........................................................... .. -------------- •------------ _ Date ..../ ..3�J.......... Final Inspection b - ...................................................... . .. . . �. ._.. EH 13 2h 1-68 R'ev• � SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M , r