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FOW OFFICE USE: ..'a. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. '- ........................... This Permit Expires 'I Year From Data Issued Date IssuedA'a��0 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 ................ IeP.................CENSUS TRACT Owner's Name -•-•••. . ... ��!�._....... ......................�� -= ----•- -4-�1-------------•--•----• ...................Phone Address ........ .............. Contractor's Name .... City JIf��Ci ..... _ ---�..... .......................�....... ------ ...._ _......................License #4PPS`+OA_-- Phon.e ./..�.. ---. . Installation will serve: Residence 0 Apartment House d Commercial []Trailer Court 0 Motel ❑Other ---T4/� ------ ----_--- A G Number of living units:-........ Number of bedrooms _ �..... 6 . . Garbage Grinder Lot Size ..... Water Supply: Public System and name ....................... .......... ........ ..-.---••---• - - --------------------...--•-------...-•--------..........................Private Character of soil to a depth of 3 feet: Sand C] Silt❑ Cloy,0 Peat❑ Sandy Loam fo Clay Loam D Hardpan o Adobe [] FIII'Materiol ------------ If yes,type ...._..__................-. (Plot plan, showing size of lot, location ofsystem 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,) �f PACKAGE TREATMENT j ] SEPTIC TANK J Size..... kr W.-,y.�-. if -------..._ Liquid Depth ...�.................. Capacity /40,0-0..... Type O�6...CASP(Material...................... No.C Compartments �._�_......... Distance to nearest: Well �1� /0_cl•........Foundation .... .............. Prop. Line 1-.............. LEACHING [ ] Noof Lines Q_________. ._ r LEACHING LIE . _._ i _. Length of�ach li�e._.._.��............... Total Length .....1lp.-�? ..... . `D' Box _1----- Type Filter Material 1Z Depth Filter Material ..___ .................... Distance to nearest: Well _.-, __.__...,... Foundation _...._____. ----------- Property rLine /46,.....—....... SEEPAGE PIT [ ) Depth .................... Diameter Number - Rock Filled Yes d No ❑ Water Table Depth .Rock Size Distance to nearest: Well ....................... ...Foundation ------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# .................................... Date Septic Tank (Specify Requirements) ....................................... F. -•-- ,- Disposal Field (Specify Requirements) - ' = .. .... -•-•---•--••••--- ----------• - --•r ....... ---•----....---•-•---•---- Draw existing and required addition on reverse-side) I hereby certify that I have prepa`r`ed 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 folfowingr= "I certify that in the pelprmance of the,work for which this permit is issued, I shall not employ any person in such manner as to become subject ma ompensation laws of California." Signed e... /. � t_ . ._-''-- `....................................... Owner . . . ... ........ ..... ........_.. By ... .. (!f : ............................•- Title ................oth. er than owner) .--------•-•-; .......................................... Fa DEPARTMENT USE ONLY -� APPLICATION ACCEPTED B.. ...... �...I , f s--.. -----------------------••---•---------••-------•-. . DATE BUILDING PERMIT ISSUED .........:......:. - ADDITIONAL COMMENTS -------•------...-•---------------- ............................. ......................DATE ............. ......................••-. -- _ "--_-I... ---=•�==",':"-----=----------- .------------•-------------------- Final Inspection by: ," f�---• ---------f-----•--•-------•------------------------------------------- ................. .�1._ . r.................. ....Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.3-3 24 1-'68 Rev. 5M 7I,7,3 '1 u •