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FOR oFF1c-- USE: APPLICATION FOR SANITATION PERMIT ------- --- ..-----------•- -- ---------------- Permit No. �. 7-Z'�-�---� - (Complete in Triplicate) -_---- ---------------------_-----------_-------. This Permit Ex Cres I Year From Date Issued Date Issued ---1-._7 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 .__1�i ��'T ! .( !-n- ------- � CENSUS TRACT {---------------- Owner's Name ------ m- __r1-l_5 ---------------------• ----------------------------•---- - Phone .- f� � � ! Ci _J?- ,¢-1I1------------------------------------------------ Address ---------------`�� s>`.��----�.�'- ------------------------------------------------------------ tY - ------- Contractor's Name}'�_ �+_C� �'�_5---- Q--P-7f--�' - -- -------.License # _ gh0k511---- Phone �r � - -• Installation will serve: Residence F J Apartment House,[] Commercial ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- j Number of living units:------ Number of bedrooms __=__1—_ __Garba_ge Grinder ___________ Lot Size ----- ------- Water Supply: Public System and name --------------- ---------------•------------ ---------------------------------------------------------------Private I Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loom ,[:] Clay Loam ❑ Hardpan ❑ Adobe 0( Fill Material ------------ If yes, type ---------------------------- (Plot __----- -----------------(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-----------------------I------------------------ Liquid Depth -------------------------- I Capacity ------- --------- Type -------------------- Material---------------------- No. Compartments { r _Foundation -___________ _-_ Pro Line ---------------------- --------------- LEACHING ___--_____ Distance to nearest: Well --------=----------------------- - ------ P• ----------- LEACHING LINE [ No. of Lines _._____1__________--- Length of each line__�`�"% ----------- Total Length _______________ Q 'D' Box ___. ----- Type Filter Material ___ :�-�/--.'Depth Filter Material --------f_9__"--------------------- .1 Distance to nearest: Well ------ Foundation -------- Property Line - �� Number - ___________ Rock Filled Yes No 0 SEEPAGE PIT � Depth .___-�-�--___ Diameter _____ __ _ -------- --�-� � Water Table Depth ----------------- ------------------Rock Size :- Distance to nearest: Well ____, _+ __ ------------------Foundation ___ Q____�_ Prop. Line ___ ��----.. REPAI AITION[ ev. Sanitation' Permit# -------------------------------------------- Date-----------------------------------) ' ------ Septic Tank (Specify Requirements) --------------- .o 74----; J 1/r�, Disposal Field [Specify Requirements] --------------- - .-=----_ �-:'L _ /# - --------------------- -x --------- --------- - ------------------------------------------------------- (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 LocalMealth 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, 1 shall not employ any person in such manner x as to become subject to Workman's Compensation laws of California." Signed ------- ---- --------- -----------------------_----------------- Owner 4 t -- -- ------- } d � B a Title (If other than owner) F o FOR DEPARTMENT USE ONLY 4 APPLICATION ACCEPTED BY - ------------------------------------- -------------- - ------------- DATE ---- _'a - 'N?4---------------- _._ . .. -------------- BUILDING PERMIT ISSUED -- ----------- ---------- - --- --------------------------------- -------DATE -- --------------------- -- -- - ------- ADDITIONAL COMMS ` - ---------------------------------------------------------------------------------------- --------------- ------ - -=--------- - --_ �� 1'" r--------- -------- ------ ------------------------------------------ = ------------------- ------ -------------- - --- -- - ------------ -- --------------------------------- Final Inspection by: -------------------------------------------------- -------.Date ' SAN JO UIN LOCAL HEALTH DISTRICT,. E. H. 9 1-'68 Rev. 5M