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{ FOR OFFICE USE: - ;& PLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. _ U ---------=----------------------------------------------- This Permit Expires 1 Year From Date Issued Date issued _ ._-�L__7� 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 inicompli ce with County Ordinan .e No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ATIO 111k CENSUS TRACT Owner's Name -------------- = + --- - --- -- ---------------------- _ ----Phone ------------------- Address ------ -3--- -- ----- --- Cly ------- City '-------------------------- -------- k Contractor's Name ---4 --------------------------------------- --------------------.License # - - Phone Installation will serve: Residence ❑ Apartment House❑ Commercial❑Trailer Court i❑ r { Mote! ❑Other -------------------------------------------- Number of living units:__________ Number of bedrooms-3__ Garbage Grinder ------------ Lot Size --Z5 I%© /' f Water Supply: Public System and name ------------------------_ �_ _ Privpte ❑ ---------- Character of soil to"a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam �Glay Loam ❑ ` Hardpan ❑ Adobe-❑ 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,] bV PACKAGE TREATMENT SEPTIC TANK:[ Size------------------------------------------------ Liquid Depth ----------------•---------Ca acY - TYa - ater-al---------------------- \ No. Compartments ----------------. .--• I Distance to nearest: Well ------------------------------------Foundation ---------------------. Prop. Line ________ LEACHING LINE" P] No. of Lines __.___________________ Length of each line--------------------- ------ Total Length _________-___.....________ ` 'D'-Box __-I- _ -:Type Filter Material _________________Depth Filter Material _______-__ -------------------------------- E Distance to nearest: Well _______________________ Foundation ------------------------ Property Line. __-_______._--__-_-_ Depth ----- --------- ---- Diameter E------ Number ------------------- •._- SEEPAGE PIT " ' - ---- --------- Rock Filled Yes I] No .i0 L ] _ V -X i Water Table Depth -=--------------------- I--------------------Rock Size -------------------------------- ' Distance to nearest: Well ___-_--_ _-_ _'_____:____ '�. . ---- ----Foundation ----------- -------- Prop. Line ---•------• ---------- REPAIR%ADDITION(Prev. Son tation Permit# ----------------- --------------------------- i { Date ---------------------------------- Septic ---------------------------------Se tic Tank (Specify Re urements1 ---- ----------*-------------------------- ----------;------j- ------ ------------------------- Disposal ± Field (Specify Requirements] ____ `. --- --- _ ---- ------ L--�------- .- 1i ------------------------------ -------------- ](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, on'd Rules and Regulations of the San Joaquin Ldcal;Health District. Home owner or licen- i 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 W/Ior man's`Compe anon laws of California." Signed ' -y -- ----- Owner BY ------- ---------------- ---------------------`-----•-------- --------- Title ---------------- (If other than owned FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY fr_-- BUILDING PERMIT ISSUED --�_--_-- - -- - -- ),1'2- -- -- o--- r - --- DATE -------"--"--9-------7----0 ------- ---- -------- ------------------------------------ --------- ---------------- DATE --------------- ADDITIONAL COMMENTS ---- ---------------------------------------------------------------- ---------------------------------------------------------------------------- -------------------------------------------------------------- - ------------------ ------- ------------------------- - --------------------- ----------------------------- - - I - - Final Inspection b ---------------------------------------------------------- Date 6'`z�=�7C _ SAN JOAQUIN LOCAL HEALTH DISTRICT , E. H. 9 .�1-'b8 Rev. 5M.