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FOR OFFICE USE: f APPI*ICATIQN FOR SANITATION PERMIT �/ /f-.6 -6 = f-� (Complete i Permit No: _lP/�-d(�// " p n Triplicate) -- - -------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued ------------Ir 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/LOC TION .-- __-- -- -- - -- - -- ----- ------------CENSUS TRACT --- ' .............. j F -G�- --- -- - ------ - - -----------------.--------- Phone _ _' 9 Owner's Name + Address _/�`�� --- -- ---- City �/ Contractor's Name C� License # a �?, ---- Phone -Z��`�`- --- ------------- ' Installation will serve: Residence Apartment House°E] Commercial :❑Trailer Court ',❑ Motel ❑ Other ------------------------------------------- / Number of living units:__,__ Number of bedrooms _�r---Garbage Grinder ...e.---- Lot Size ------------------------------------------ Water -________________ ______________________Water Supply: Public System and name ---------------------- ----------------------------- ------------------------------------------------------l-Private` I Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam ' � a Hardpan ❑ Adobe '❑ Fill Material ___________ If yes,type ___f ____________________ (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,) {A y h PACKAGE TREATMENT [ ] SEPTIC//TANK Size�7�aX_ _�______________ Liquid Depth ___S._________,___.- 1 Capacity�Cp a-4-__ Type� - Material L� ---- No. Compartments ------ Distance to nearest: Well -11 __Foundation _- d__-__-_---_ Prop. Line IL • ----------- LEACHING LINE Y"kK No. of Lines __.__ ______________ Length of eac line__/_�-__� ______ Total Length --- ........... i QQ * D' Box -___ --- Type Filter Material 5''- _ le-Depth Filter Material -----A-EJ______.__-__ ---_ ___ Distance to nearest: Well %5.�--------------- Foundation __1D!_________ Property Line - --___-___`-_ --- ___ Diameter , �- --a___ Number ___-___+ ______________ stock Filled Yes Na SEEPAGE PIT X Depth _� Water Table Depth ----940--_---------' --- -----------------Rock Size �__*_a------------- f --- ♦� --________ Prop. Line ,f_ f_/ r.yTtiDistance to nearest: Well - - i ___ _____- u REPAIR/ADDITION(Prev. Sanitation Permit# __r------ ---------------- ----M_______ Date _-_______________--._______-______} Septic Tank (Specify Requirements) ------------------- -----------------------------------------•-----.-,----------------------------- DisposalField (Specify Requirements) -------------------------------------------------------------------------------------------------------- ---------------------------- --------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------I------------------------ ---------------- ---------------- ------------------------ - -------------------------------------------- (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 Saco 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^e work for which this permit is issued, I shall not employ any person in such manner as to be a sub' ct to%Wo an' ompensatio s of.California." Signed _ - ----- ------------ Owner By -------------------------------- ------- , --f---- ----------------------- Title ----:----- ------------ (If other an owner) ERARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ----- - --------•---------------------------------- ------ DATE ------ 0_7._�------ _ ---------- BUILDING PERMIT ISSUED ------ --- -- A G--_---- - -- -�- ----------- - -- -- -----�-----------------'----------------------------------- -------DATE ----------------------- NTS ADDITIPNAL ---- -- ----- - ---- - ---�� ----- ---------------------------- ------------------------------------------- ----------- ------------------------------------------ - ------ --- &_--------- ----- --- ------ ----- -- ------------------------------------------------------------------------- ------------------- ------------------- -------- -- s ----------------- ---------------------------- ----------- - - -- --- -- ------------------------------------------------- -- -------------------------------------------=-------- ----------- - Final Inspection by: ------- -------------------------------------- •-------- ----- -----------------------.Date _- !1 =y.--- AN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.