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I FOR OFFICE USE: 1 _ APPLICATION FOR SANITATION PERMIT ------ --------- --------- (Complete in Triplicate) Permit No: --------------- 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 i described. This application is made in compliance.with County Ordinance N 0.--549 and existing Ruled and Regulations: JOB ADDRESS/LOCATIO j - �Kl ---------------------CENSUS TRACT- -- - --- --------------- Owner's Name --------------- - -- - ------ ---- -- --- ----- -- ------•--------- ---- --- hone __ � Z / Address ----------------------- - ----5 -,l/------- - ---- ----- --- Cit Contractor's Name ---------- --- __ ______._,License #�/�,, --- --------------- -- €J .� ----- Phone 71-_6-A(0_7 Installation will serve: Residence X Apartment House[❑ Commercial ❑Trailer Court i❑ Motel ❑ Other Number of living units:----- ----- Number of bedrooms ___-Garbage ri de __ _. ___._ L ize 7X �� ------------------ Water Supply; Public System and name _______________________ ,," -------------- ❑ Private E]Character of soil to a depth of 3 feet: Sand' Silt Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ AdobeX Fill Material ------------ If 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, ---- - ---------- - Liquid Depth ---�.-----,� t Capacity -- __";ATYpe ---- Material (�� _ �— , No. Compartments -••-----•••- Distance to- nearestWell F ------Foundation ----------- ------- Prop. Line -----1d:. `�] .'4 LEACHING LINE No. of Lines 1______________ Length oUOc ine_ r�-_� --- Total Length --------�----------- 'D' Box ____.'._.-- Type Filter Material ___Depth F I erMaterial .... - --- -------------------• , Distance to nearest: We([ ----- wFoundatio d__-`- Property Line _____/Q__10_ SEEPAGE PIT [ Depth ___2_S__`____Apia eterr� " _ * ---- ter •�f_- Number _.. ------- ------- Rock Filled Yes ' No C] a Water Table Depth -- __ Rock Size � --------------------t / _ Distance to nearest: Well -____ _____________ Foundation - i 1 - Prop. Line �0.-•------- REPAIR/ADDITION(Prev. Sanitation Permit# ______________ _______ bate ---------- p k (Specify Requirerrmems) . ------------- - --------- ----- Se tic Tan I 4 [ Disposal Field (Specify Requirements) _ ------ i --- --------- -------------------------- �- z- --------------------- ----------------------- -------�------------- � ------ � - ------ (.Dra.wiexisting and re on reverse side) - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin t� 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." a _ fi Signed --- "� .Owner /f --- -''-- - --- �-;�:�-j_ •-��- By ------------- ----- -- -------------------------- --Title -------- - - ----------- ot an owner) . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _. --+--- BUILDING PERMIT ISSUED ------------------------------------ . DATE ..__,�L,� - - ADDITIONAL COMMmo DATE ------------- ---------------------------------- ------------ ------- ---- - - ---- -- ----- ------------ ----- - ----- ---- -- ------------------ ----------------------------------------------------- --------- -- -------- --- ---- Final Inspection by: ------ -- --- Date �/_ � = ----- ----------------------------- AQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M