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FOR OFFICE USE: T APPLICATION FOR .SANITATION PERMIT } (Complete in Triplicate) Permit No. .7/_-_q_F_ . -_-____--___ This Permit Expires 1 Year From pate Issued Date Issued '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: ' P i JOB ADDRESS/LOCATION ------, ----------- -------------- CENSUS TRACT -------------------------- Owner's Name ....... Phone7�--�/ �� Address ------ ------ City 1 -- -------- ---- ------- - 10— ]� Contractor's Name i ________ _____ _ License # . _ d'9�'/ Phone Instailation will serve: Residence ) Apartment House❑ Commercial :❑Trailer Court i❑ 3"t Motel ❑ Other / -... r r Number of living units ------ Number of bedrooms -__ Garbo a Grinder --- -------- Lot Size Water Supply: Public System and name ---------------------------------- _ _________Private Character of soil to a depth.of 3 feet: Sand[] Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ 5 Hardpan ❑ Adobe V Fill Materia( ------------- Ifes, type YPe --------- ------------------ , it {Plot plan, showing size. of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) NEW fNSTALLATION: - {No sep#ic_tank.or seepage pit.permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT. [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth ------.----------------_-- F Capacity ----------- -------- Type ------------------:_`7-Material---------------------- No. Compartments ------•-- -- } Distance to nearest. Well a ----------=------'`"-;-� ------Foundation -- - -------------- Prop. Line -----------.. - :------ __ LEACHING LINT: (>(J No. of Lines --------- __ -_ Length of-each ------- ------ Total Length .-_..Y d_ _ 'D' Box --_-I----- Type Filter Material ---.:___'._____Depth Filter Material ----f_9'_`'-------- Distance to nearest: Wel! ___--sFoundation ---U! _ Pro Property Line yyJ -1 l� SEEPAGL. Depth __./1._ 'yameter ----------------_ Number --------_t___/----------- Rock Filled Yes,] No 0 t t T Water' Table De th�___---__ --------------- -----------Rock S ize -------�-� --------- Distance ------ to nearest: Well -----------------------Foundaton -._ Q5"__';7`Prop. Line __1 --------__-- i AI ADDITION rev. Sanitation Permit# �__..______ Date`------------------------------= ' Septic Tank {Specify Requirements) ------- ------ ----- -----r-.•' ,. ^ - s Disposal Field (Specify Requirements) -_____------- -6 .� .. --------------------------------------------- ___________________________________________________________________ ________________ F -------------------- __ ____ __ __ --- ----- - - - - (brow exists -r, 1 F 'n and required a clition on reverse side) ~- - ;I hereby certify that I have prepared this:application and that E the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules"tind 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.". F Signed - ---------------- - Owner , Title _:.- By - --_ � } (If other than owner) FOR'DEPARi ENT USE ONLY + APPLICATION ACCEPTED BY --- ---- -------------------------------- ---------------------------------------------------. DATE k�_ -------: a BUILDING"PERMIT ISSUED ----- e�------------------------ DATE '--------------- ADDITIONAL COMMENTS ---------------------------------------------- ----- ------------------------------------------------------------------------------------------ -----------A------ -------------------- -------- ----- ----- -------------------------------------------- ----------------------------------------- b : -- ----------------- ------------------------------pecion ___________________________________ •�_� P � --------- ina ns D , I M_f ate# __ - "- - -- ` - - --SAN. JOAQUIN-LOCAL. HEALTH-DISTRICT E. H. 9 T-'68 Rev. 5M