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FOR OFFICE us€: APPLIC'ATION FOR SANITATION PERNiTT/ I Permit No: ---------- ---- ------ [Complete in Triplicate) --- - --` Date Issued -- 70_7--� - ti ". This Permit Expires 1 Year From Date Issued --------------------------- ---------------------- l 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 ADDR '� � , "• -----CENSUS TRACT -------------- ----------- ESS/LOCATI N ___I _ _� :--- c--� �G :Phone 9;Z--- --------- Owner's Name ------- --------:57 �. --------- -------------------•-- CCity " !' Address -- - , Phone ------ - --------- - --- cense # ---------:Contractor's Name ___ ` ---------------- - Installation will serve: Residence 44;Ament House fl Commercial❑Trailer Court r Motel E]Other---------- - f -r k Number of living units:---Jf------- Number of bedrooms -�-----Garbage Grinder d4--- Lot Size ___ __ _- -1�---------------------- Water Supply: Public System and name ----------------------------------------------------------------------------------------------- -------------Private r � ❑ y ❑ y fl y Character of soil to a depth of 3 feet. Sand Silt Cloy Peat❑ Sand Loam Clay,Loam Hardpan❑ Adobe Q Fill Material ------------ If yes,type---------------------------- r (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 seepa a pit permitted1f public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTICTANKT �7� �e_� __ t' __ _/ ------------------- Liquid Depth ---5!_C---------,----- Capacity - ��---_-- TYpe ' -------- Material_ ��x°r e No. Compartments _--~ -------------- !` i Distance to nearest: Well ----_ f�P__'__________________Foundation --_ --------------Prop. Line--- =-------- 1J t I LEACHING LINE [ ] No. of Lines ------------------------ Length of each line----------------------------Tfltdl Length -----------_--------• -- r I ___Depth Filter Material ---_-_----_ 'D' Boz, -- -------- Type Filter Material ----------------- -------------------------------•- � Distance to nearest: Well ------------------------ Foundation ------------------- Property line. -------------------=---- 4 SEEPAGE PIT ( I Depth - ---------- ---- Diameter --------------- Number ---------------------------- Rock Filled Yes 0 No Water Table Depth -------------------- - - - ------------Rock Size 1 Foundation �- Prop. Line ------ --------------- Distance to nearest; Well ----------------------------------------Foundation REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------- .. E' lit 1� w__ - Septic Tank (Specify Requirements) ----------- _� - -- - -2" I -------------------------------- Disposal Field (Specify Req u irements) ------------------------------------------------ ------------------------------ -------------------------------------------------------------------------------------------------------------- ________ - -------------------------------------------------------------------------------------------- ---_------------------------------------------------------------------- ---- --- 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 oaqan- County Ordinances, State Laws, and Rules and Regulations of the.San Joaquin Local. Health Distriict. Home owner oor lice-- sed agents signature certifies the following: i "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 becomsu ect to Wark .at!s mpensation laws of Callf6mia:' .i- Signe ------------------------------------ or -------------- - Owner = - 1-- By -------------------------------------------- I - --------------- Xitle -- ' -------------------------------------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ' ---- ---------------------------------------------. DATE ----6-� � -��%�----------- BU1LDING PERMIT ISSUED.--- - ------ - --------------------------------------------------------- -- ------------ ----- ------DATE: : -- COMMENTS -----' ---------------------------------------------------------- -- - =----------------------- ADDITIONAL ------------ ------------------------- --------------------------------------------------------------------------------------------- ---------- . -------- ----------------------------------------------------------------------------------------------------------------------------------------------------- ----- - - - Final Inspection b ` ------ --------- -----------------_-- Date - Y- ----- --- _ ----- SAN JOAQUIN LOCAL HEALTH', DISTRICT E. H. 9 1-'68 Rev. 5M.