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R FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT y Permit No. . (Complete in Triplicate) 7� 1( ____._-_-._____ This Permit Expires 1 Year From Date Issued Date Issued _/_7�7 .. t--- ---------- 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 co,/m,pliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCCAAjTION J,2__4?;' ��' /��P/T`------- t - CENSUS TRACT Owner's Name ./_�w-------!44?;' - -------------------Phone Address G�r2 ��------/%IYT171�------------------------------------------- City �0-_Z215_;e1 r----------------------------------------- Contractor's Name ---, 1!_ �1. License #IZPhone __ Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court E] Motel ❑Other -------------------------------------------- Number of living units:---/____ Number of bedrooms _ ------Garbage Grinder 11Q_ Lot Size _ - ----- -------- --------------- Water Supply: Public System and name --------------------- ----------------------------------------------------------------------------------------Private,o . Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobes( 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 ( I SEPTIC TANK f ] Size-----------------------------------_------------ Liquid Depth ____-______--___-_______ 4 j Capacity -------------------- Type -------------------- Material---------------------- No. Compartments _._._______..._..-••-- `; Distance to nearest: Well -___________________________--____Foundation ----------------------Prop. Line ...................... .J LEACHING LINE [ ] No. of Lines _ _________ Length of each line_ .____-__-____ Total Length 'D' Box ------ ----- Type Filter Material --------------------Depth Filter Material -----------------------------------...------ Distance to nearest: Well __ -------------------- Foundation ------------------------ Property Line -__-____-.-_-__-__--__ SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number .--------------------------- Rock Filled Yes ❑ No Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well -----------_____________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) --------------------------------------------------.----�-------------•------------ ---------------h----------------------------------------- Disposal Field (Specify Requirements) -----10::�d.v ------ --- -- ----._____-___ - ------------------------------------------------------------------------------------------------------------------------------------------------ --------------- ---------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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: "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 ----------------------------------------------------------------------- (If other t n o r PARTMENT USE ONLY APPLICATION ACCEPTED BY ------ _-____-_ ___-____ DATE ---- -- ------ ------------------ BUILDING PERMIT ISSUED -------- - -1-`- -- ------ - ----- --- ------ ---------------- -- - ------ ----- -----------------DATE -------------------------------------- ADDITIONAL COMMENTS ------------ --- ----- ---- --- --------------------- -------------------- -----------------------------: f -- 3 J—7-7-/------- -r l rhl'-�r 1 I- JF- �' 5 -----------------------41 -- ----- ----- --- ---------------------------------------------------------------------------------------- - ------ - ----------------- SANFinal Inspection by: ---------- ------ - -- --------------------------•----------------------------------------Date -----i__-7�� OAQUIN LOCAL HEALTH DISTRICT (�E .% ' E. H. 9 1-'68 Rev.