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FOR OFFICE USE: APPLICATION FOR' SANITATION PERMIT ------------- ------ - -------------------------- Permit No. ''(Complete in Triplicate) _ �� _-_--_____-__-_-_------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued ----�13 6l`2 Application is hereby made to tWS n Joaquin Local Health District for a per 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 .�S_.-+_-_��_._ + CENSUS TRACT' _=_..�____._.._ ,r�� Owner's Name � A /- f =� --------------Phone _ ,---'-�g--�!'_.---- 3-- ----- �_4 r-------------------------------------- Ci - ---�� .y.-- -------------------------------------- 3 ----- - - Address -�-�- � 1� . / tY � f -- --- -------------------------------- ,t Contractor's Name - �Y --------- -------- --------------------------- ----------License # � PhoneJ �---7=� Installation will serve: Residence artment House❑ Commerciat ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number ------ -------------------------Number of living units----/------ Number of bedroomi�___-.-.Garbage Grinder - ---- Lot Size Water Supply: Public System and name ----------------------------------------------------------------------------------------- ---------------------Private Character of soil to a depth of 3 feet: Sand'[�Ilt:❑ Clay ❑ Peat❑ Sandy Loam ,❑ Clay-Loam ❑ Hardpan ❑ Adobe ❑ Fill Material -- --------- If yes, type ____________________________ As (Plot plan, showing size of lot, location of system in,relation to wells, buildings, 'etc. must be placed on reverse side.) �l NEW INSTALLATION: (No septic tank or seepage_ pit permitted if public sewer is available within 200 feet,) p ee � PACKAGE TREATMENT SEPTIC TANK - Size-- - 7 T - -- Liquid Depth - .Q_________________ [ ] [� �-'_----- --//-� � --- -- --- - q P ate. Capacity� ____ Typ - Material( 1 No. Compartments ______________________ .r Distance to nearest: Well J.- _j__________________Foundation _ -F__________ Prop. Lim __--______ LEACHING LINE [11 No. of Lines -- -------_.--__ Length of ach line-__�0--- Total Length !-A40 ___________ y �f 'D' Box __ Type Filter Material 4Ve��__.Depth Filter Material ,LJ�____ _______________________________ Distance to nearest: Well --- Foundation __________ Property Line,._ ________________ �� SEEPAGE PIT [ ] Depth -------------------- Diameter ------ ---------- Number ---------------------------- Rock Filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----_-------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _________________---_____________- r SepticTank (Specify Requirements) -------- --------------------------------------------------------------------------------------•----------------•---------------------------- ------------- (Dra existing and required addition on reverse side) Z��(� 4f.-W* Pj I hereby certify that I have prepaied 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." i Signed Owner -tet B "i+• Title f� / rP-_ Y _ . . If ofiher than owner ( 1 ~�^ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------r---a-13---r ------------------- ----------------------------------------- DATE --- ?� -= ,-7/----------- BUILDING PERMIT ISSUED ----- ----- -------------- -----------------------------------_-DATE ------------- ----------- -------------- -- ------------------------------- - -- ADDITIONALCOMMEN S ---------- ---- --------------- ------------- ------------------------------ ---- --- ------------------------------------------------------- ------------------------------------- ------ =--------- ---- ---------- - ------ - -------------- -- ----------- ------- ---------- ------------- -------------------- -- -------- ----- --- ----- --- --------------------- --- - Final Inspection -- --- ate --- --- ---- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M