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FOR OFFICE USS 4 ` APPLICATION FOR SANITATION PERMIT C.I (Complete in Triplicate) Permit No. _�_�r__-D-�.e ------------------------------------------------------ - „ __..__ _______________________ _________--------------- This Permit Expires 1 Year From bate 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: JOB ADDRESS/LOCATION ----------------CENSUS TRACT -----(f-------------- Owner's Name - ----- �� ------y- �-�--AP,0�---------- --- ----------Phone ---------------------------•-- r .� Address `�� 7L' City - - Contractor's Name 249, 0_ ____ _ ____________ ________.License # Phone"4_" _, / ss Installation will serve: Residence XApartment House❑ Commercial ❑Trailer 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 Clay ❑ Peat❑ Sandy Loam '-4. Clay Loam Hardpan ❑ Adobe-❑ Fill Material -Na- If yes,type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse °s.'ide:) 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 _____________,_ LEACHING LINT= [ ] No. of Lines _______________________ Length of each line---------------------------- Total Length -----------_-------------- V ----_.__-_,_.----- .--..__..'D' Box ------------ Type Filter Material _______________,___Depth Fitter Material -------------------------------------------- Distance __________ _______________________________Distance to nearest: Well ------------------------ Foundation ------------------ = - Property Line - --------------•--••--- SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes Q No :i[] Water Table Depth ------------------------------------------------Rock Size -------------------------------- k Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- 1 RlEPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------_-------------------} Septic Tank (Specify Requirements) --------------------------------------------- ------�- -------- Disposal Field (Specify Requirements} ------�� __-4a.4 7---- ---- -��--1�'------ �Yl r"-- ........... -------------------A-DP.ia-D --to----F.XU5-r1_r-v-r,,-- y _A/1-------T-------- -N�------------iA/]-r--H -D-'-•' )e?K. - -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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, Slate Laws, and Rules and Regulations of the. San Joaquin Local Health District. home owner or licen- sed agents signature certifies the following: ' "1 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." s Signed -------- ------ ----- ------ Owner BY ------------------ �i ,.- ------------------------------- - Title ---- ,�_ --------------------------------------- ' f other than owner) �} 'p FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 4--a-f1- --------------------------------------------------"4--------------- DATE -------� ------- BUILDING -- BUILDING PERMIT ISSUED ----------- -------- -- �-----------------------DATE -------------•----------------------------- ADDITIONAL COMMENTS - - ------------ ---------- _ - a' ------- - ---------- ' _ ----- --------------------------------- ------------------- U ------I - -----X__ —. ------------------------------- - F Ins e p - - =� � --- --- -- - - ---- --------------•- -- --------- -------------------.Date ----��~ - SAN JOAQUIN LOCAL HEALTH DISTRICT f o E. H. 9 1-'68 Rev. 5M'