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FOR OFFICE USE: APPLICATION FOR SANITATION P RMT. ----- - �'' Permit No: _ -_ �_,el (Complete in Triplicate) Date issued -------- This Permit Expires 1 Year From 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 Regulations: JOB ADDRESS/LOCATION � r aa �"___CENSUS TRACT ________________---- ---- Owner's Name -------G �J------------- ----.Phone------------------------------------- Address --------�-!Q- r l City `------------- ----------------------------- Contractor's Name �� _.,� - 3 License # 1 - -,�.9�Phone ---------------------- ------ Installation will serve: Residence ❑ Apartment House`❑ Commercial : railer Court ;❑ Motel ❑Other ---------------------------•---------------- -. Number of living units_ ___=�_- Number.of bedrooms __Garbage"Grinder __"_ Lot Size -_----_-"_______________________________ Water Supply: Public System and name - -------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ CI ❑ Peat❑ NSandy Loam❑—ClayLoam`❑_ 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 seep -e pit permitte��d/Jif public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ r Size7" /t__ �_______________ Liquid Depth _ ----"f_-__ Capacity "..J_c�d�_ Type - Material___ -.. No. Compartments _ ----------- i i i Distance to neares : Well ___k__-/a�________-/�-------Foundation __-_-_- -------- Prop. Line rj'_________________ O f LEACHING LINE ,- No:-of Lines.;'__'_ _-------------- Len th of each fine_._'-'� _,P" Total Length ______________ --=------------ D' Box _ _ Type Filter Material'_'_s _-_,____DepthtFilter Material __./V---__--"_---- P.._.. Distance to nearest: Well _____I_,F2_ ________ Foundation --"- 10-------.-- Property Line. ____�_� _ ___________ SEEPAGE PIT [ Depth __c -' _f____ Diameter __ _______ ___.-__- __,� i 0 �,� _ Number ____..___� J Rock Filled Yes�No I --------Rock Size J9 -- �/� Water Table Depth ---------------------------- ---------------- __________ Foundation s i -------- So l __ ion -----�Q--------- Prop. Line ------`-�_------•---•- Distance to nearest: Well �__________ _______ r - 4 REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----- --------- ------ Date ---------------------------------- -- ----------------------------------------------- ) Septic Tank (Specify Requirements) --------------------- .. ' ---------- ----'------------,_--------------------------- - l' Disposal Field (Specify Requirements) --------------------------------------------------------------------------------'------ ------------------------ ---- ---------- I-------------------------------------------------------- ----- --------------------------------------------------------------------- f (Draw existing and required addition on reverse side) 1 hereby certify that 1 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 _--_"_--_ Owner --------- -•- ----------- /� -- ---- -- . Title - - (If other than owner) F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ / ---------------------------------------------------- ------- DATE A ---�------------------- . BUILDING PERMIT ISSUED ------------ DATE ------------------------------------- ADDITIONAL ----------- -- FADDITIONAL COMMENTS a76 `�� a ------ --------- ---- ---- - ------ ---_-_---- -------------------------- --------------- ---- ' -------------------------------- 1 ------------------------------------------------------------------------------------- ------------------- -----------------— == c� =_a= = --------- - ----- - -- ----- -------- - --- - - - -�/ Final Inspection by: ------1- Date SAN JOAQUIN LOCAL HEALTH DISTRICT o E. H. 9 1-'68 Rev. 5M _—