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FOR OFFICE USE: I�A - APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: 3-- -- gQ-.7J3 - ---- ---- ---- - This Permit Expires pires T 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 Ode in compliance*y�t� County i nee No. 549 and existing Rules and Regulations: � �',"`�. d tG' JOB ADDRESS/LOCATIOW ._-_J - -------CENSUS TRACT ---------------------- Owner's Name ---__..- ---% � -_�,1 (�i / _Phone _ Address ---------- .-.d---- --- --------------------------------------------- - Cit r Y --------------------- -- Contractor's Name - T --------------- .License # Phone fes ' - Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court Motel ❑Other Number of living units:------------ Number of bedrooms ____________Garbage Grinder ----------- Lot Size -------------------------------------------- Water __Water Supply: Public System and name - ------------------------------------ ___Private ElCharacter of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .❑ Clay Loam .E] 'j Hardpan ❑ Adobe ❑ Fill Material ------------ if yes, type -_ ________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must placed on reverse. side.) .` NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available wi in 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK:[ ] Size------------/.�6_(�.- -A --- Li uid Depth __________.____ .__ _ _ Capacity --------------------- Type 0,_ �Ma eriai-----_--- - ------ No. ompartments -------------------- -9 - Distance to nearest: Wel! ____ 9---------------Foundation__.____-_-- - Prop. Line LEACHING LINE . k [ J No. of Lines _______- ___ _ Length of each line__ _ _ - Tota Length ,_________ ---------- 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -----------------------I-- Distance to nearest: Well ___,--( _ ---_- Foundation ______.1Q-�____ Property Line. ----- --------- SEEPAGE PIT [ ] Depth ----------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes L No i❑ Water Table Depth ------------------------------------------------Rock Size !' ---------------Foundation -------------------- Prop. Line -----------------•--- Distance to nearest: Well ______________________- 1 i REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------- _ Date Septic Tank (S ecify Requirem nts) ________________ ------------------------------------------------- ----------------------------- ------------------ Disposal Field (Specify Requ reme ts) _____ �_ -------------------- --------- ---------------------------------------------------------- -- ---------------------------- ------ --- - _ -------------------------------- --- ---------------------------------------------------------- ------------------------ ---------------------- --------- --- - ---------------------- I ( raw existing and required addition on reverse side) Y 1 sere y certify l at I have pr paredlthis application and that the work will be done in accordance with] San Joaquin unt►, .dietanc(es, State Law , and ufes and Regulations of the San Joaquin local Health District. Home Ior liven- */s d ag�nts,�s ina ure certifies t +I�o ing: certify that in he performs ce of t e work for permit is issued, I shall not employ any person �wner n such manner as to become su I c o ork an's pen i aws aIiTo1r- Signed --- -------- - ---------------- --- Owner BY - ------------ -------------- --- ------- --------------- ------------------------- --------- Title --------------- (If Cherthan o ner) -------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B DATE BUILDING PERMIT ISSUED - ------------------------------------------------------- ------------DATE -------------- NAL COMMENTS ----------------------------------- --- ------------------------------------------------------------------------ - ,. ----- --------------------------------------- ---------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Final Inspection by: ------------------ --------------------Date --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5Mi �� ' Y /77• 7 Of