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d FOR OFFICE USE: .,APPLICATION FOR SANITATION PERMIT p ----------- ----------------"------------------- Permit No. 4: . . (Complete in Triplicate) Cr. This Permit Expires 1 Year From bate Issued Date Issueds��a._��- --------_--------------------- ----------------- --_-- Application is hereby made to the San Joaquin focal 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 --�----A----- -3----- CENSUS TRACT Owner's Name C4 I �;' h e --------- --- -- - -----------ti = f t on Address ----------------- la �-7 City ---- � ------------------------------------- Contractor shame " Q% - V !� . '-.License # _/-Lf r/---� Phone-- _ ,- - --- �,. Installation will serve: Residence ❑Apartment House,❑ Commercial ❑Trailer Court 0 Motel r]Other --------------------=-------- -------- Number of living units:..--}�---- Number of bedrooms ---'-k_Gi rbageiGVihde( --- ""L6t`-Size__- �- x_.--40-9--------- r`� [ Water Supply: Public System and name ----- --------- ------ ` .111 ` Private ❑ I Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay ❑ Peat❑ Sandy Loam •❑E Clay Loam;❑ Hardpan❑ Adobe FillMate ria a ------------ If yes,type -- ------------------------ (Plot plan, showing size of lot, location of system,4i.n,,!elation to w.p s„4buildings, etc. must Oe placed on reverse side.l NEW INSTALLATION: (No septic tank or seepage..pit permitted if public sewer is available within 240 feet,}- -rS' ------- PACKAGE TREATMENT [ ] SEPTIC TANK'[f] z ize_- --=,-------------- ___ ------------- Liquid Depth ----------------: -----• LJ Capacity --------- ---------- Type ---- Material ---------------t-- No. Compartments -------------- V ------- ------. Distance to nearest: Well - ----------------------------------Fp undation��3' -( _ -___ Prop. line ._-.____________._.___ LEACHING LINE [ ] No. of Lines --------- -- --- --- Length Aof each line-- -------------_-----___- Total Length ------------------- -------- � r I � # 'D' Box ------------ Type Filter Material ----__ ) A-----Depth Filter Material --------------------•----------------------- Distance to nearest: Well ---I------ --- Foundation -----_�-_-----_--___ Paperty Line _--_.................. SEEPAGE PIT [ ] Depth ____-- ------------ Dia, i eter ____--_-_--_---- Number --_-----_---.------------_ Rock Filled Yes E] No Water Table Depth ,,---------- ----------------------------- ----Rock Size --------- i Distance to nearest, Well ----r~ { ---,Foundation ndation -------------------- 1P rop. Line ----------•---- ------ REPAIR/ADDITION(Prev. Sanitation Permit# . Datei ---------------------------------- Septic Tank (Specify Requirements) ----------------- - 1`' . f------- - - ----------- L ----- --- ----- ( ----- Disposal Field {Spedfy Requiremen s) f Q Lr r-• J � `r --------- -------- ---------------------------- � --- -- ------------- - -\,, ------- ------ 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 San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San..,a in Local Health District. Home owner or liven- sed agents signature certifies the following: "I certify that in the performance of the work-for which this permit is i su�,'I shall not employ any person in such manner as to become subject to Workman's Compensation`Icws<:of Cal 'sfo r a:' Signed ----------------------------------- ----- ------------------ ------------ Owner �- By-------------------�- - ------ - --------------------------- Title `-tel' (If other th owner) FOR DEPARTMENT USE=ONLY APPLICATION ACCEPTED BY .--- --------------------=------ ----------------------------------- DATE -•------------------- BUILDINGPERMIT ISSUED -------------------------------------------- --- ' --- - ----= --- ------------------------DATE - ADDITIONALCOMMENTS --------------------------------------------- - ------------------------------------------------------- --------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- -- -- ------v� t------ ---------_::==---------------- ----------------=------------------------------- ---------- Final Inspection by: ------------ ----�1-%�- � �---------- -------------- --- _------------------------ Date SAN JOAQUIN LOCAL HEALTH DISTRICT E, H. 9 1-'68 Rev. 5M.