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k FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------ -------- ---------------------------- (Complete in Triplicate) Permit No: --------------------------- -------- This Permit Expires 1 Year Fromr bate issued Date Issued -_`f-__f _-6g Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein 4 described. This application 71 ,ty, de in compliance with County Ordinance No. 549 and existing Rules and Regulations: d. JOB ADDRESS/LOCATi a--�.- -----------------------------':I�—�'[1It.�- US TRACT --------------=----------- Owner's Name . _k --- -------- ----------------- ------ ------Phone t Address ------ --------��_05 - ----- ---------------- - ---------r-------- -- - ----t Cit rJV � f v ------------ Contractor's Name _--.___.- -- --=---- -------------License#_-/- 3" hone : Installation wilf serve: Residence Apartment House-E] Commercial:[jTrailer Court Number of livin -unitsof bedrooms -----Ga bage Grinder -- --------- Lot Size Water Supply: Public System and name ------------------ _ __ _ ----- Private cter ofs - -------- - - Charcoil`to a depth of 3 feet: Sand0' Silt. Clay Peat❑ S-andy a Lom ❑ Clay Loam Hardpan Adobe'/ ------ 0 Fill Material ------------ If yes, type -------------- -------- (Pfot'plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I NEW INSTALLATION! (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ' PACKAGE'TREATMENT"("]--SEPTICCTANK'C l ,� Size--------------- ' ------------ --------- ------ Liquid Depth - --------- Capacity -------- ------------`'Type -------------------- Material---------------------- No. Compartments -------------• Distance to nearest: Well ------------------------------------Foundation ---------_------------ Prop, Line "_-------------- --- LEAC RING LINE [ ] No. of Lines `----------------- Length of each line---------------------------- Total Length ----------- ---------------- 'D' Box -±.-- >__w Type Filter Material ------------- "Depth Filter Material Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line, } EEPAGE PITDepth - ---- ------ - - Diameter Number ------------- Rock Filled Yes El No i[) Water Table Depth ---------- --------------------------------------Rock Size # Distance to nearest: Well ---------------------------------_-_ -.Foundation i - ---------- ------- Prop. Line ..-------------- REPAIR/ADDITION -•---- (Prev. Sanitation Permit`# -------- ----------------------------------- Date A _ "-"----- Septic Tank (Specify Requirements) --------------- Di�alField�(Specify Requirements) ----------------- ----- J — --- -- ----- ----------------- ------------- Z ------ --- -------- - ---- --- � 6 ++t ------- --- ---- ------ -------- ----- (Draw existing and required addition 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 1 shall not employ an as to become sub'ect to Workman'sPoensation laws of California." p y y Person in such manner -Signed ".-- -- ----- -------------- ---- ---------- Owner BY ------- ------- ---- -- - --- Title (If other than owner) -------- FOR DEPARTMENT �USE-ONLYAPPLICATION ACCEPTED BY DATE- - -- --- --- - - ----------------------- -------------- — -"-4P- BUILDING PERMIT ISSUED "________________ -�------ _____-""-_ADDITIONAL COMMENTS ---------- -- ------- -- -- - - ----------------------------- --------- - DATE ------------------------------------------------- ------------------------------------ ---------------------------------------------------- - - -------- --------------------------------------- ------- Final Inspection by: -- ——_ ----- = — _ —_= _ _.- ------------------------------ ----------------- - -------------- Dated. ,SAN JOAQUIN LOCAL HEALTH DISTRICT i 1 E. H. 9 � 1-'68 Rev. 5M "