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FOR OFFICE USE: „ m ------------------------------------- ` APPLICATION FOR SANITATION PERMIT ------------- --- [Complete in Triplicate] Permit No. ----------------------------------------- ------------------------------------------- i ii Date-__ This Permit Expires 1 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: OwB er'DS NarnSeLOCAeION 7 :----G----O --- ----------CENSUS TRACT 011E Address _L.(,?FIL19�--------------- Cit �� i' Contractor's Name ---� Y - - --- - -------------- ------- -------- �' t 5-: License �a. - --------- --------- Phane - c _ Installation will serve: ResidenceX�pcirtmentHouse,[] Commercial ❑Trailer Court MMf Other-------------------------------------------- .Number of living units:--- umfbd ooms -� _-_---Garbage Grinder --- -_ Lot Size _9-�_--- � t � - Water Supply: Public System''and name --_________________ ____ ---------------------------------------Private ]c�� C7heat[J , ,Y� t Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clays � - -and. Loam ❑ Clay Loam:p/ F it 3 Hardpan ❑ Adobe EJ Fill Material -- -___ If yes, type --�4_ --------------------- (Plot plan, showing size of'lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (Noseptic tank or seepage pit permitted if public wer is a ailable within 200 feet,) PACKAGE TREATMENT ��/ L � 'r [ 1 ;F SEPTIC TANK Size--.- �'" _- ------ Liquid Depth ----7 ------- Capacity Type -------------------- Material- n �I_C_ No. Compartments --- ------•.-,• Distance to nearest: Well ----- ------------ ------Foundation ------ - ---------.prop. Line ----s !.EACH WG LINE. [ J No.1iof Lines -------�?----__---_-- Length of each line.---- ---------------- Total Length ---r _ a_.•---------- 'D' Box 4-------- Type Filter Materia! VC—A--_---Depth Filter Material - o _ Distance to nearest: Well ..- ______________ Foundation -1 a--_______-.--___ Property Line. .____S-_-- - SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ r Water Table Depth ------------------------------------------------Rock Size . ------------------------------ Dista 11 nce ---------------------------Distance to nearest: Well --------------------- _---___----_--Foundation -------------------- Prop. Line -_------------------ REPAIR/ADDITION _----___-_-_. _REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _--_-_--._--_--___ Septic Tank (Specify Requirements) -------------------------------------------------------------- i _________________ __________--- Disposal Field (Specify Requirements) �° "_"_' `' - , - -�------------ --------------------------------------------------------- �� it -- ------------- - ------------- ------------------------------- (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 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -------- - -------- ------- Owner -�, BY --- ) J�-- T �� f f - Title - ------ -- .Cs� .c0af- - -------------------------- (If other th owner - ----------------------------- - 11 FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY ii---_-------- __--_-,_ ATE /� �., BUILDING PERMIT ISSUED ----- -`----------------------------------------------------- --- --------------------- --------- - - -DATE ---------- -- t' - ADDITIONAL COMMENTS -----0-- ----------------------------------------------------- { ! ------------------------------------------ --------------------------------------------------- --------------------------------------------------= r ---------------------------------------------------- -------- ----------------------------------------------------- -------Fi - - io - b ------------------- --------------------------------------------------------------- � Final Ins ection b -��- � - - ------ --- ----------- �r Date .i SAN JOAQUIN LOCAL DISTRICT + E. H. 9 1-'68 Rev. 5M I