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FOR pFFICE USE: APPLICATION FOR SANITATION PIIT - - ------------ -- ---FI - , - (Completein Triplicate) Permit No. ------------------------ This Permit Expires 1 Year From bate Issued Date Issued _-.=1� > 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 complia ce with County Ordinance No. 549 and existing Rules and Regulations: JOS ADDREOS LOCATION --- -_ �- ------CENSUS TRACT - Owner's Name 1�_ hone.77 _7_�_.> 7. Address f--- ------ - -- --- --- -- --- ----a-/-.-1• - •-. --------- , Cit Contractor's Name -:----•--.License # . --------------- Phone ----- Installation will serve: •Residence [:]Apartment House,[] Commercial []T Motel ❑Other Number of living units-----J----- Number of bedrooms -_--. _...Garb age Grinder---------- Water -- _- -_-_ Lot Size _.---y _� � � �IZQ --------•-- Water Supply: Public System and ,name ----=--=---=-,___::�--__-___ ._, =-===----=•--=-------•-------------------------Private Character of soil to a depth of 3 feet: Sand 0 Silt o Clay .0 Peat❑ Sandy Loam. Clay Loam Hardpan ❑ Adobe Fill Material ------------ If yes,type ----•---------------------- (PI'ot 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 permitf'ed if public sewer is availab'ie within 200 feet,) \ PACKAGE TREATMENT { ] SEP IC TANK Size_____________________________- _- I ----------j--- Liquid Depth ------------ --------•---- Ca aci YP _.._._ ---.-_ _ _ r� P tY - T e -- INiaterial - -- w_ No. Compartments ...................... - I P Distance to nearest: Well ----------- ------- -----------Foundation ----------------- Prop.prop. Line --_------------------ LEACHING LINE [ Na. of Lines Lengthe`adi line ------ Total Length - 'D' Box =---------- Type Filter%1 r .__-__-___- ------- Depth Filter Material -.----;. -------------- ...... Distance --- - Distance �o nearest: Well --------!- 1_-----!_-. Focrndation _-------------------- Property Line •----•--------•--•-=- SEEPAGE PIT -- -- ] Depth --- ---------------- Diameter ------------.� Dumber ------ Rock Filled Yes No f0 Water .Tale Depth 1.,. r �^ p $ =---..1j c1Lize ----------------- Distance ----••-•------• Distanceonearest: Well -__._--_-___- -------- ____________ •-Foundation ---------- -- Prop. Line --------- ............ REPAIR/ADDITION(Prev. Sanitation Permit# ........ ------ Date ------------------ ) Septic Tank (Specify Requiremehts) ---------------- _ - t Disposal Field (Specify Requirements) ,-_ ------------------- I-------------- --------( -- - •------------------- -------------------- --•--- ---Draw existing and required addition on reverse side) ------- I hereby certify that I have prepared this application and -that he work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health Vstrict. Home owner or licen- sed agents signature certifies the following: :" -� - L "I certify that in the performance of the wor;N for which this'-4"'t"'t is issued, I shall not employ any person in such manner as to become subjectjto Workman's Compensation laws of Callfonia." t AY i igned ----------- ------------- __--.---- wner, - By ----------- __ - - ---- f-., .1 } - t -__ � RE; Title -- -- • f #her t . .` '. owner) -------- - - ---- - ---- ` FOR DEPARTMENT-LUSS ONLY APPLICATION ACCEPTED BY ---_ Ip ----------------- - - --......................................................... - -- ---- ------- - --------- DATE BUILDING PERMl�'��ISSUED ------------------------------------ - - ------ - ADDITIONAL CQ1V1Mi:NTS ------------------------- - - - <--------------DATE ------------------------------------------ -----------�/ -----------------------r-------•----- -----------------��-�f�-�::�-fit-':--- _t �--- - ----------------------- -•---------------- _j - ---------- -------------------------------------- Final Inspection by; ------ ---_---- P Y r:f: s �"� • --------•---•-- --•-•------•----•------------------------------ ----------Date ------ •-�---P. i.- - - ., -• -- ' SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M