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FOR OFFICE USE: PPLICATION FOR SANITATION PES IT tPermit No. � ./ ?:3v----------- 0 . (Complete in Triplicate) ------------ O • -------- ------------------------------- This Permit Expires 1 Year From Date Issued Date Issued 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 io JOB ADDRESS/ ATION�a, 4Ah_ n �b .� ' ''`"j► J( CENSUS TRA __________________ __ C� / Owner's Name_ "- --- ------ '' -4' ---------- ----- - -----------------Phone --------------- --L'--pry-I_�- ---- /�r!{ -- < -- ----------------- City � ------------------------ Address J y Contractor's Name ?rl "� ^"" ,.�._ -� o.---.License #IZPhone Installation will serve: Residence ❑Apartme House❑ Commercial oTrailer Court ;❑ Motel ❑Other ---•___. Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size --------------------------------------------- Water ---_-_ _____--__________•--_------.-_. Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ ,Silt❑ Clay ❑ Peat E-] SandyLoam E] Clay Loam C3Hardpan 1[E Adobe E] 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.) `( NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) L PACKAGE TREATMENT [ I SEPTIC TANK [P� ize_--�----.�a__X_ ---------------- Liquid Depth _ --------------------- Capacity'Y'- `'-r Type = -_ iWMaterial.�'- ------- No. Compartments ................. 4 / i J1 Distance to nearest: Well -_.-.-___1©a✓'___________________Foundation .-.-.f L`.____...__ Prop:Line ____ _.___.._____-- LEACHING LINE [l] No. of Lines ------- _--------_------- Length of each line------/4L'_`----------- Total Length _.%L'4i.................. D' Box .--_ Type Filter Material ----4_R:._c__.._.Depth Filter Material _.Ay----_______________•_--.-__--_-.---- Distance to nearest: Well _..- ----------- Foundation _:__lq- ------------ Property Line __S..... :.......... SEEPAGE PIT [ Depth --- '.�.------.- Diameter ____ __-____ Number --__------_./._ .------- Rock Filled Yes No ❑ ` , / - Water Table Depth -------------------------Rock Size -312..-- �/l------------ -----=------- - Distance to nearest: Well -------------------------Foundation ....IC------______ Prop. Line .�--------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) 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 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 -- J------------ -------------------------------------------- Owner Title f0 By ... -- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . -------------------------------------------------- -------- DATE1�---------------- BUILDING PERMIT ISSUED - 1 __: �.___ -____. -__-_ /DATE G r� 7 ADDITIONAL QMENTS ::P_.1 .... DATE •�a E ' = ------------------------------------------------------- -------------------------------------------- ---- - -------- .� W ------- - --- - - - --- Final Inspection by: --------- SAN ------•--------------------------------- ---------Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1•'68 Rev. 5M