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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r - {Complete in Triplicate} Permit No. r --------- ------- ----- -------------- p sued Date Issued ---7-Jr -- -------- ---- This Permit Expires 1 Year From Date Is Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application i r�aCle yn compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION._ / - -�---4,100•y6er------- - ---CENSUS TRACT - .l Owner's Name -------Z41)V11F1-11_ =--------------- i J maLrsti_ PhoneAddress ------s ' jCity -------------------------------------- Contractor's Name ---- License # . -- -------------- Phone ------------ ----- ----- ------ - - - - - - lnstallation will serve: Residence partment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -___-__ Number of living units:.....!_--__ Number of bedrooms ----,__Garbage Grinder --____--_-_ Lot Size ______________. - Water Supply: Public System and name ___________________ -------------------------------- Private r Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Gay 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: fNo septic tank or seepag pit permitted if public sewer is available within 200 feet,} PACKAGETREATMENT [ ] SEPTIC TANK![+ Size S �,` �?r�7_ - ---- Liquid Depth ------ -- -�� Capacity [)_---__ Typ Material--� G-----No. Compartments p �-------------- Distance to nearest: Well ld------------ r — 0, - ----��- ----- ----------Foundation --- -- --- - -- - - prop. Line .----�----=-------- LEACHING LINE [ No, of Lines _-_ --___-___-__-_ Length of each line �Q_ /v - ----- ------ Total Length -------• ------ 'D' Box .--_- Type Filter Material -Depth Filter Material ____-_-__4 l Distance to nearest: Well __--� ..__ --- Foundation ,�49--- -------- Property Line -----4��.......SEEPAGE PIT [ ] Depth ------�--- ----- I Diameter ------------ --- Number --------------- ------------ Rock Filled Yes ❑ No i❑ Water Table Depth ----—---` "— ---- ----Rock Size ------------------•------- ------ Distance to nearest: Well ----------------------- ----�`---------Foundation _. -__._ --------- Prop. Line -------------------•-- REPAIR/ADDITION(Prev. Sanitation Permit# ________________________ _ - -------- ------ Date ---------------"'---------- _ Septic Tank (Specify Requirements) --------___________ - --------------------------- 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 erfor a ce a ork For which-this permit is issued, I shall not employ any person in such manner as be�� ect, pensation laws of California." Signed d -- - , '- - ------ -- ----------------------------------------- Oweer - --- --- -- ------ - -- --•---- Title _.. (If other than owner) --------- ------------------ ----- - FOR D ARTMENT USE ONLY APPLICATION ACCEPTED BY c- " BUILDING PERMIT ISSUED r-------------- DATE --------- -------------17� - -------- - ------- ITIONAL COMMENTS -- ---------- ----------- ------- - ----------- r r ------------------- ---------------------- --------------DATE - -------------------- --- ------------••-- ----------------------------------------------------------------------------- .------------ ------------------------------------- ---- ---- -------------------------- ---- ------------------------ ---------------------- ---- ------ - - -- - - --------------------------- - -- ------------------------------------------------------------------------------------------------ - ---- ------ Final Inspection by ----- -------------------------------------- ------ ------------------------ Date ------------- ------- - j - -- SAN JOAQUIN LOCAL HEALTH DISTRICT ; E. H. 9 1-'68 Rev. 5M