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FOR OFFICE USE: ZAPPLICATION FOR-'`SANITATION PERMIT < /a: i pie n Triplicate) Permit No. ________________________________.________.____._-____. This Permit Expires Year from Date Issued Date Issued Application is hereby made to the Son 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 _.11_-------✓ .- L f'1 ---------- - ---------- ----------CENSUS TRACT --.----_----------------_- Owner's Name 1.4 --------------------------------- - Phone AddressQ � ------ ------------ City - --- --------------------------------------------------------------•---•-- - f,. � -S Contractor's Name ` ---------------- --- -----------------------------------License # --------- ------------- Phone ---------------------•-------- Installation will serve: Residence 1�*artment House[] Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- E Number of living units:_.._._----- Number of bedrooms _______Garbage Grinder _'?W---- Lot SizeJ�_ 4t`__________________ , Water Supply: Public System and name ______________________________ -----------------------------------------------------Private I� Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay 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.) 5 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer ii available within 200 feet,) PACKAGE TREATMENT I I SEPTIC TANK{ J Size------------------------------------------------ Liquid Depth ---------------- --------- Capacity ----------- -------- Type -------------------- Material---------------------- No. Compartments ------------ ------ Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ---------------------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- Distance to nearest: Well ---_-------------------- Foundation _____________________ Property Line _______________________ SEEPAGE PIT [ ) Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No ❑ 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) ----- � _____��_- -3 �e �- .rrJG--------_ ----------------------------------------------------- ----- ------------------------------------------------------------------------------------------------------- ------- ------------------------------ (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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed _...._.___ Owner --- - --------- By ---- Title ------------------- ---- ---- ---- ---- -------------------- - ----------------------------- ---------------------------- (If other than owKer) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ;{` � YrG �� - - DATE Com-- = �7 :__ :i BUILDING PERMIT ISSUED ----------------------- ------------ ----------------------------- -------DATE - --- -------------------------------- ADDITIONAL COMMENTS ___ __________ - -------------------------------- -��"b .- - R ---Q is -5^----Y� 3 -------------- ---------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- ------------- - - ----------- - - - - - --- - ---- --- -------- ---- --------- ------- ---- ----------- ----- ----- Final Inspection by: ----- Date a --- -�---�-r---- SAN .10' QUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M i