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FOR OFFICE USE: APPLICATION FOR SANITATION ,PERMIT ___ Permit No. (Complete in Triplicate) - --- ----------- ---------- _____ _________ -------------- ---- --------------- This Permit Expires 1 Year From Date Issued .a 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 witFl County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ION ----- -�y__-,__-- --_�``'-- - ----------CENSUS TRACT -------------------------- -----.--- [ Owner's Name -'---- --------- _ tT/ V---- -------------------- - --- Phone _ . ----------------------- - ------ Address . � _ _ . f t .��--------------------------- City ------- I---------------------------------- Contractor's -------------- ---------- F Contractor's Name ---.L:fir[f _ _t _-_______________License # _r _sy� _ Phone -7- �J I - Installation will serve: Residence W<Partment House-[:] Commercial:❑Trailer Court i❑ Motel ❑ Other ---- --------------------------------------- Number. -------------------------------------Number.of living units:fi_J.-__ Number of bedroo s ____:__Garbage Grinder _-____ ---- Lot Size _. 4_� :L_. _®_____________ lWater Supply: Public System and name -------------- .g1 :_ _ _ _4---------------.----------------------------------f------Private ❑ Character of soil to a depth of 3 feet. Sand`[] Sift❑ Clay, ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ Hardpan ❑ Adobe)< Fill Material ------------ 1f 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,) PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth -------------------------- _ Type -------------------- Material-_----------.---_ ---- No. Compartments --------------------- + f•, +�a G Capacity ------------------- YP - p -• SSI ' Distance to nearest: Well _________________________________Foundation ---------------------- Prop. Line _-__________._________ G LEACHING LINE [ ]• No. of Lines _r__________________._ Length of each line---------------------------- Total Length ----__-____-_______________- 'D' Box ---------- _.Type.Filter Material ___________________Depth Fitter,Material __---_______________________________________ t Distance to nearest- Well ________________________ Foundation ------------------------ Property Line __________________-_-___ SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No .l❑� Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance --------------------------- --Distance to nearest: Well ----------------------------------------Foundation -----------------.__ Prop. Line ----------------------E REPAIR/ADDITION(Prev. Sanitation Permit�# -------------------------------------------- Date ----------------------------------). � Septic Tank (Specify Requirements) --------------- - ----� -------------- t , --------- - I Disposal Field (Specify Requirements) ---- ---- --- ------ Cj_ ----------------- G�tr�•��-( -- .----------- ----------n----------------------- -- ------------------------------ --------------------------------------------------- ------ ------- .----------------I---- -------------- �3 {Draw exi ting and required addition on reverse side) 'h I 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. Horne 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 be su jecf to ork n's Comp ation laws of California." Signed - -------- -- - ---- --- Owner I A k BY = Title ---------------- ------------------------------------------------------- of,Rer than ow r) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -F. ----- -- - ----- DATE ---------------- __ BUILDING PERMIT ISSUED --------------- __DATE -.._...- -------------------------------- --- ' ADDITIONAL COMMENTS --- --- _________________ ----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- -- -�_ , - - - - -- - - - - ---- ------ -- ---- ---- - ---------------------------------- --- - - --- -- --- --- ----- - --- --- ---- ----- Final Inspection by: - --------- -- - - -- -----------.Date SAN JOAQ IN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev, aM