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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 0 (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 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 1 JOB ADDRESSAOCATIION7 -__7__ ___ _� -..l 1�--- _CENSUS TRACT __________________________ A--.t,)-= -` - --- - ---------------- Owner's Name --------- Phone —. -5 Address --------- . ---`----- ------- -----�,�7 _.-- City "`.�"..� -- ------"-- ---------------------- - Contractor's Name - ---------- -- -----* ----moi-c'----------------.License # -��Jll----- Phone _ d Installation will serve: Residence XApartment House❑ Commercial :❑Trailer Court ;❑ Motel ❑Other -----------------------------------------_ Number of living units:......(----- Number of bedrooms --'5____-Garbage Grinder __________ Lot Size ----- i-PFJ-_--------------- Water Supply: Public System and name --------------------------------------------------------------------------------------- ----------------------Private Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay .❑ Peat❑ Sandy Loam ❑ Clay Loam-❑ Hardpan ❑ Adobe` Fill'Material ______.____ If yes, type :_?------------------------- IV- _______________________ IV- _ < _ I - - tL(PEot 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 s wer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] �'k Size--------------'" y.-----'-- -------------- Liquid Depth -------------------------- Capacity --------------------- Type ---------------------- Material_'"------------------- No. Compartments --------------•------• `N Distance to nearest: Well ___________________________________Foundation ---------------------- Prop: Cine -----------------.------ v LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------------ ------------------- D',8ox -_s___.__-__ Type Filter Material ________________Depth Filter Material -------------------------------------------- Distance to nearest: Well ________________________ Foundation ------------------------ Property Line_ ___________._____.___- SEEPAGE PIT Depth ------------- Diameter Number ---------------------------- Rock Filled Yes Na 0. Water Table Depth --------- --------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation ____________________ Prop. Line ----------------...... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _______________________.___-_-..__) Septic Tank (Specify Requirements) -------------- -------------------------------------------=-----------------------•---------------------------„•-----------------------.... Disposal Field (Specify Requirements) -------------�-- a-d--------70--- Gc. -��I•L --------------------------------- --------------- ' '�c � cfcrr /I ---------------------------------------------------- -------------------------- --------------------=-------- ---------------------------- -------------.------.----------- --------------------------------------------------------------------------- (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 liven. 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 became subject to Workman's Compensation laws of California.” Signed -------- ---------- ---- - Owner �j�- -BY ---- ------------------------------- Title --- -----------/_-- -=--------------------------- (Lf of a than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -__- ___ DATE __A�_ nq- . _ _a-____-____________ BUILDINGPERMIT ISSUED ------ -------------------- ---------------------------------------------------------- --------- ----DATE ------- ---------------------------------- ADDITIONAL COMMENTS ---- _ ------------------------------------ --------------------------- ---- _ ,_ _ _ =o `�^"'�_i - w-- - ------------------------- ----------------- ---- ----------------------------- ------ - - -- -- - -- -- - -- ------- ---- Final Inspection by: ----------------------------------------- --------------------Date -------- - -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M �' f