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FOR OFFICsE USE: APPLICATION FOR SANITATION PERMIT - ------------------- (Complete in Triplicate) Permit No. ---------------------------------------------------- Dafie 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 ------ ------ ------ =--------------------------------------CENSUS TRACT -------------------------- Owner' - p - ------- Owner's Name -------- c1z!/,1u ------7��tr2 !-4 ------------- - ----Phone --- -72 City ---`"--------------------------•-- Address ----------- -------------------------------- ---------------------------- _ Contractor's Name ��c `� �.---- _12 p_r�� - --o— --------License # -_ .�� r _�__ Phone _44c��212� Installation will serve: Residence A Apartment House[] Commercial [-]Trailer Court l❑ f -Motel F-1 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❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 I Hardpan ❑ Adobe 06 Fill Material ------------ If yes, type ---------------------------- (Piot 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,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------- ------------ Liquid Depth ---------------------.----- Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------- -------------- Distance to nearest: Well ------------------------•-----------Foundation ---------------------- Prop. Line ---------....--------- ff a LEACHING LINE % No. of Lines _ �_l1__ ____I---------------- Length �of each line -------- Total Length _____ _._____.....__ s 'D' Box ---- Type Filter Material ------ __,Depth Filter Material ------ ----------------- Distance to nearest: Well -- Q --- Foundation ----220/-------- Property Line __ .............. SEEPAGE PIT ' Depth ___Zl. -'-Diameter A7,401 ____ Number -----------J-------------- Rock Filled Yes ,� No 0r i1 Water Table Depth------------------ --� -------------•- -----Rock Size -------� ------------------- -1 � F ,Distance to nearest: Well .......< ej--------`.-------...Foundation -49-0-7---- Prop. Line ...�T 4----------•- S REPAIRf pITIO_W rev. Sanitation Permit# ----------------------------- -- N.Date ------------------------------------1 ' Septic Tank (Specify Requirements) --------- ------------------------------------------------------------ ------------------------------------ - ,.. Disposal Field (Specify Requirements) --- - -----, �1 �Te�� --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ___________ ------------------------------------ (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, 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 shah not employ any person in such manner as to become subject to Workman's Compensation laws of California." iSigned ---------------------------------------- - --------------------------------------------- Owner ff r. -----. Title ..-_.Clv�.�P �---- BY - - -------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ ---------- - ---------------- -� ----------------------------------- DATE ------- -3 111------------------- BUILDING PERMIT ISSUED --------------------------------- -- DATE ADDITIONALCOMMENTS ------------- ----------------------- ---------------------------------------`-------------- --------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- - --- ------------------------------------------------ ------------------- ------------------------------------------------------------------------------------------------------------------- -------- ---- ---------- ----------------------------------------------------- - - ------------------------------- ------------------------------------------------------- Date = Final !ns ection b ------ - 7 •-- - -------- - ------------------ �- �-- --- AN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M