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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .....................................................•-•- � Permit Na. (Complete in Tripiicatel ... . 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 ith County Ordinance No. 5rl9 and existing Rules and Regulations: JOB AiaDRfSS/LOCATI /9�.75� �7//� �� --�- - CONSUS TRACT .............•............ .__.....� _!........................ ..............-.. Owner's Name ;;:!.7 �.... :Phone ----•---------..._...............Addres _..--••-• �� ...._ .. City ..�� ..................-- •.......... ti� _ Contractor's Name --------------- --------------------c � -- ----•-•-----..... .............. icense 94t --' Phone Installation will serve: Residence portment House Commercial{]Trailer Court 0 Motel❑Other { Number of living units:___...._:. Number of bedrooms .._:.Garbage.Gaage Grinder ............ Lot Size - - -__.__._____ Water Supply: Public System and name .:........... '`Private Character of soil to a depth of 3 feet- Sand E] Silt❑ Clay ❑ Peat 0 Sandy Loam Clay Loath.p Hardpan❑, Adobe 0 Fill Material ............If yes,type............... .......... (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on rev�tse side.) NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) � 1 PACKAGE TREATMENT [ ] SEPTIC TANK Size................................................ Liquid depth ......................... Capacity. ------------- --- Type ......... ----- Material...................:__ No. Compartments ..:...._._........:-- .Q Distance to nearest: Well ....................................Foundation ...................... Prop. Line ..................�, ,..1 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 [ I Depth ......•------------- Diameter ...............- Number ............................ Rack Filled Yes ❑ No O Water Table Depth -----------------•••••••--- ....................Rock Size ............ .................. �. Distance to nearest: Well _---_•..................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ...................I.......................I Date __._.____........_._..._._____.---) � r Septic Tank (Specify Requirements) ................. D' asal field (Specify Requirements) r.. .....-•-.•-- - .?_ ---,..-•----•-•------•---•_---_------ r ------ --- ---- �1 l s'�... � o � .�- -r � - �---------------------- .........- ----------- ------ .........--------.,.........-----...--• -� ----------------------------------------------.....-.----•------••-----•-•----. --•-------------- .................................................. (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 9 County Ordinances, State Laws, and Rules and Regulations of the San .Joaquin Local Health:District. Home owner or Iicen- 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 becorne subject to Workman's Compensation laws of California." Signed _...--------_---------------- •----------- Owner BY --------------------------------------L4.2 �._ _.-. Title -- --_-- (If,other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -•---- ----------I—............. ----------• - --------1. DATE ...��.� BUILDINGPERAIT ISSUED ---------------------------------------------------•-------------------------------- --------------.DATE _.---------------- ......................... ADDITIONAL COMMENTS ..-----------------_-•- - -------------------------•------------ ------------•-- -----------------..-...--------------•-------------------------.....------------------....-----------------------------•--------- ......... ------------- ------------------------ Final inspection by: - ....... ........Date .. EH 13 2h 1'68 Rev. 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7II 3M