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FOR OFFICE USE: , APPLICATION AOR SANITATION PERMIT ----------------------------------f 0t y ir------------- ". 0�2 {Complete in Triplicate) Permit No: ----- " ---"--------------- 1 r'. This Permit Expires 1 Year From Date Issued Date issued l__'__._'-__--.. 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 Regulations: r JOB ADDRESS/LOCATION - .�,__- 1•-- i _ � /--��`.-----� ---_CENSUS TRACT -----------------------... Owner's Name ----------------------------------------------------;--V�,_,"7 Phone ------------------------------------ Address -----a� fs�� i ------ ------ --------- --------------------- ------- --• City ------------------------------------------ --------- Contractor's _-- ---Contractor's Name -----_ �J >�r------------------ License # '162- Phone ' ir _" 4 / -- Installation will serve: Re'sidenc 'Apartment House ❑ Commercial Trailer Gewt ',❑ r Motel EJ0ther -------------------------------------------- /� Number of living units:"__ __"__ Number of bedrooms,_�_-_____Garbage Grinder / __ Lot Size!_s!' _4 �°.�-- --------------- or Water Supply: Public System and name -----------------------I-- -----------------------------' ---------------------------------------------------Private, i } Character of soil to a depth of 3 feet: Sand'❑ Silt❑_- Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ' Hardpan ❑ Adobe ❑ Fill Material ____________"df yes,type -________________________ (PI'ot 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 seepagexpit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT J ] SEPTIC TANK Size__ _ �f_ `_____.____:__---- Liquid Depth ______________._____ Ca ac+t y____,__ Type' i-- -Material-�_�V _'`°_ "__ No. Compartments __ --------------- (�► p Y d� t � � Distance to nearest: Wel _ _____________________Foundation_- _-_________._.�Prop. Line _ .___:_______. LEACHING LINE No. of Lines ------/--------------`k Length of each line --------- Total Length ,M9________________ Pt ' 'D' Box/)/V__ Type Filter Material/� Depth Filter Material Z_-k?-------------------------------------- Distance --___________________________ ______Distance to nearest: Well _-_ .09 _k0C� r�-_--•_ --f_ Foundation _/-�-------------- Property Line -� -- ----.01----_-._. SEEPAGE PIT J'4' Depth f____ Diameter' _.:� ______ Number "- __""_"________ Rock)Filled Yeso No [3s,1 Water Table;Depth lam' `------------ -1 -Rock Size `' ................ istance to nearest: Well ------- -_-`_a.�f_____'--------------Foundation, ---------- Prop. Line _ -- ---- _________ REPAIR/ADDITION(Prev. Sanitation Permit# -------.----------------- _--- --Date---________ ________________} i Septic Tank (Specify RegvareaieAis) ----- - - ----------- ---------- ---------------------•--K--------------------- ----•.--------------------------- Disposal Field (Specify Requirements) ------------------- .' ~ -------------------------;:---------------------------------•---•----------- .E ----------------- ----- ------ ---- ;-=` ---- ` (Draw existing-----=--- -----------------------------------------------.:-------- ------------------------------------------------------and required _ ` = I addition on reverse side) f II I hereby certify that I have prepared this application and�that the work will be done in accordance with San Joaquin 1� s County Ordinances, State Laws, and Rules and Regalafions'rof 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 wl�icli't7iis per`mitis issued, 1 shall not employ any person in such manner r as to become subject to Workman's Compensation Ows of California." a '� Signed ---- -- -------- - -----. Owner. - - ------"---------- -- --- -- -------------------------- BY ------------r ------------------- -- o�t - - -- ---- - -- - - ----------------------------------- -title __�� ' - (If r an owner) � r �'. ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- ----------------------------------- ----------------- DATE. ---------- BUILDING PERMIT ISS-U,ED - ------- -------------I--------------------------------------------------DA-T-f ------------------------------------------ ADDITIONAL COMMEl ifs _--___-- --- r --------------------- -------------------------------------------------------------------------- - - ------ ------- --------k-------------- ---- -----------------------------------'---------------------------------------------------------F----------------------------------------------"-------•---_ ` ---------- ---------------- ^ Final Inspection by: __ _ 101-19-112C " -��-------------- ---------------------------- SAN ' Date SAN JOAQUIN LOCAL HEALTH DISTRICT >_. H. 9 1 '68 Rev. 5M �` C \`; `°; x"