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FCC))R OFFICE USE: 3 0APPLIfATION FOR SANJTATION.PERMIT T r (Complete in Triplicate) Permit No:--.7 L _____________ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the Sari 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 ADDRESSAOCATION _ ,� ._-- �� --------- - _ --CENSUS TRACT -_______________-------- Owner's _ _ __ Owner's Name -._ f,2- __ ''?? -------------------- - --- ,,��A� �- =i.� Q- J�✓ / ------------------ -------------Phone Address `' ��7r"r -----------------------_- Contractor's ---•----------- --------------- -------�--------•--. City --� �� --- - ------------ - Contractor's Name --_f� 3�_�j�j ' _ ', �/� '-------------License #�Z� Phone i Installation will serve: Residence;&Apartment House-[] Commercial ❑Trailer Court ❑ i I � Motel ❑Other t Number of living units:_/------- Number of bedrooms _ r + Garbage Grinder __ Lot Size X— Water Supply: Public System and name -------------______ _______Private E] t - ------------- Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ , Sandy Loam E] Clay Loam ❑ Hardpan ❑ Adobej(] 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.) ISN NEW INSTALLATION: ' [� {No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ I SEPTIC TANK [ Size_ = ---------------------------- Liquid.,Depth ---------- -•-----'-- E 1 + Capacity-------------------- Type -------------------I Material:------ ---------------#. [ Distance to nearest: Well --------------7- t-----------------Fouhdation ---------------------- Prop. Line'-,---------- ------ LEACHING LINE [ ] a No. of Lines -------------------------- Length ofach line---'------------------- ±--- Total Length ----------- ' d ---------------- 'D' Box ------------ Type Filter Material. _ -------- --------Depth Filter Material ---------- ------------------------.....--••- 9. Distance to nearest: Well ________________________ Foundation _ Property Line SEEPAGE PIT [ ] Depth ____________________ Diameter -------------:•'Number ----------.----------------- Rock Filled Yes ❑ No i❑ Water Table Depth ----------------------------------- ' =-------------Rock Size ----- --------------------•---- Distance to nearest: Well -.--------------------------------------Foundation -------------------- Prop. Line -------------:......... REPAIR/ADDITION(Prev. Sanitation Permit# -._____-.-----_____--______ r -------------- Date ----------------------------------} r Septic Tank (Specify Requirements) __-_ /j/ jL_____.� -Q ___ -Y �jf y-� fC _ Disposal Field (Specify Requirements) - ..... �L 2 �� i ^ __________________________ _____.-________--______---_.___ _ F (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: f "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." 1 ! Signed ----- ----- ---- -- ------- Owner ..... BY ---i---- --------- -- er than er) -- - Title - - - -- ------------------------ o } FOR DEPARTMENT USE NLY R APPLICATION ACCEPTED BY_ DAT a- BUILDING PERMIT ISSUED _ ___-_______ ------------- -------------- ---�---------------- ------------- - ----DATE --- --------------------------------------- k ADDITIONAL COMMENTS ------------------------------------- -- -------------------------------------------------- -------------------------------------------------------------------------------------------------- -------------------------------------- ---- ----- ------------------------------------------------ Final Inspection b - ------- -Y - -------- Date - -------------------------- SAN JOA IN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M