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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------- fid.. c Permit No. � (Complete in Triplicate) ---------=-------- -------------------------------- - Date Issued „ _-- -_ 'This Permit Expires t Year From Date Issued M ---------------- ---- - IV 4 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: � n JOB ADDRESS/LOCATION t '�``J 7----------CENSUS TRACT ---------------- ------//---- ----- Phone Owner's Name .---- { � Address --�---- City � - --- 4--,- /1--` Contractor's Name ----.-.License# AW-1.5 �1---- Phone/11--`4—_F42_7. _ Installation will serve: Residence KApartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑Other -------------------------------------------- Number of living units;-----/-.-_ Number of bedrooms __5------ Grinder ------------ Lot Size _--_-__-.------ - /------- Water Supply: Public System and name ---------------------- --------------------------------------- ------------------------------------------------Private Character ot,oil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ;❑ Hardpan ❑ Adobe Fill Material ----------- If yes,type ---------------------------- (Plot plan,, sho ing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION:r--{No-septic-tank-or-seepage,pit permitted if public sewer is available within 200 feet) rr PACKAGE TREATMENT [ ] SEPTIC TANK,[ J ize_------- _- --_ ------------ ------------ Liquid Depth ---� ---- �` Capacity/M-6- -!I-- Type i------ Material---- --- --- --- No. Compartments ___��-___ LJ �.!-`---- +c ation ------la-r------ Prop. Line -------- ------------- LEACHING LINE No. ofLines nearest. Well Le, _ _ ��Found [ I ✓ . -_ ngth of each line al= = Total Length ,- � .... 'D' 13W.-_-_* _. Type Filter Material Depth-Filter Material ------le---- ----------- -------- Distancelto nearest- Well ___ __ ---_-:-;,Foundation ..___ 1---Oft ._--- --rProperty Line ________ _____________ ` ---------�.-- ��Rock Filled Yes No SEEPAGE PIT [ ] Depth --- ------- Diameter�-�--`-_-_-- Number-_ - 0 Water Table Depth --------------- ------- --- Rock Size l:_ _fit Founda ion's- -------------- Prop. Line ..-----------_---- -- Distance to nearest: Well ...____-/PjP__________________ A, � REPAIR/ADDITION(Prev. Sanitation Permit# --3------------------- --- Date - ------ ----1 — -------------------- ---------- Tank (Specify Requirements) -------------------'--�' --------------------------------------------------- ----------- ---------------------------- Septic '-" Disposal Field (Specify Requirements) ------------- `' ------------------------ = •,. -1 j------------------ ----------------------------------------------------- 4EV -1 - -- ------------------------------= ----- -------------- --------------------------------------- (Draw existing and required addition on reverse side) .i,� 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 licen- sed agents signature certifies the following: X I 1. "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. Signed ----------------------------- -------------------------- Owner BY -------- ------------------------•------------------------ Title -----'- (I other th wner) ^� z76 K . FOR DEPARTMENT USE ONLY /r#C)f; APPLICATION ACCEPTED BY ------------- '----- -- ---� DATEJ _13. 6r f BUILDINGPERMIT ISSUED -------------------------------------------------------------- ---------------------=--------------DATE --- --------------------- ----------------- ' ADDITIONALCOMMENTS -- -------------------{} �-------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- -- - --- - ---------- Final Inspection bs __ _- _ Date 2' `^ SAN,JOAQUIN LOCAL,HEALTH DISTRICT - E. H. 9 1-'68 Rev. 5M