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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. -.7T.:....// ,V. .............. -------------- This Permit Expires Z Year From Date Issued Date Issued 4.-6-7V 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 �.l._.,.... ' .�cr *�:±.,- ----------- ---------------------------CE=NSUS TRACE Owner's Name .......... .................................. U Address -----.._ � _'1..... ��' ' ................. City .._ i Contractor's Name . _..... -. .License #j� ......Q...._ o�� / 7•. I installation will serve: Residence Apartment House 0 Commercial❑Trailer Court 0 Motel ❑Other......................... Number of living units-..--/-.- Number of b roo s ---Gar Grinder :�'YLot Size Water Supply: Public System and name __—i............................... ................Private ❑ Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ - Peat j]�_Sondy Loam fl Clay Loam ❑ Hardpan ❑ Adobe: Fill Material ............ ifes a ___.-._._.____.:. y ,type ....... (Plot r (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 �' - r j l SEPi'1C}TANK Size-AV.. �--�-`�-----------. Liquid Depth ._.�.................... - Capacity/d'Q�.. Type P14� Material s- ccs No. Compartments -._ .. E Distance to nearest: Well .fig/-G - .--.......Foundation .1...- ----- prop. Line ...z + LEACHING LINE No. of Lines ._ Length of a ch line.--lLl .............. Total Length I-dGrJe 'D' Box /..._ Type Filter Material _. °r ' •---- -- .. _ -----Depth Filter Material .,�5''............. VI Distance to nearest: Welllk4--A- !1... Foundation .............. Property Line .t��----•..... SEEPAGE PIT Depth f P ��-----__-. Diameter ..... -. Number ...-• .................. Rock Filled Yes No ❑ Water Table Depth --------r9_ r------------------- --•---.Rock Size -----owl........ •• I Distance to nearest: Well ._ .......-....................Foundation ..la.... Prop. Line .... ....... , REPAIR/ADDITION(Prev. Sanitation Permit ... ) 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 k 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: t certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .............. ------------------------------------------ ------ Owner By .. ......................... Title --------ec- flif other than owner} ; FOR DEPA ENT USE ONLY APPLICATION ACCEPTED BY ....... . DATA= __________ ---_`_. '- BUILDING PERMIT ISSUED ................................. DATE _ ADDITIONAL COMMENTS . ; - ..........-•---.... ........................................•------•-•--...... - -- ...................................I.............................. ...................... ..................... --•------•• ................. :. -•----------------------- .-. -- .Final Inspectionb . f ... -•-- - -•�:!"—,r.c.�.................... .......Date ._..-. - SAN JOAQUIN LOCAL HEALTH DISTRICT 13 24 mlv E. H. ._- 1-'b$ Rev. 5M '7 1'7 n .� .,