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FOR OFFICE USE:` -' ( b ^- - APPLICA74ON LR SANITATION PERMIT ------------ --------- ----- Permit No ��: � (Complete in Triplicate) : --------------------------------------- ------------------ Date Issued __4�_ _'ll --------------------------------- -------- This Permit Expires 1 Year From Date Issued 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 c``o��,,,m��pliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION -- 4'V-____ ----------------- t -- ----- ----------1----__.__ _-_ ....CENSUS TRACT -------------_---------- Owner's Name -------�--^---�------------ ---------- --------- - - ----------- --------- -- ----------- -------Phone Address c�a:�Pl. - ......./ �+ c� Contractor's Name _,[_1/____a� r _____ _- ________.License #hv5lf_____ Phone -- ------------------ -- Installation will serve: Residenceartment House[] Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number -----------------------------------------Number of living units:______ Number of bedrooms ____Garbage Grinder _______ Lot Size -------- ------- ............ Water Supply: Public System and name -------------------------------------------- -- _-_---_-_---------_---------.-----.------.---___-_Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat E] Sandy Loam Clay Loam E]Hardpan E] Adobe E] Fill Material ____________ If yes,type ________________________ (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 [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -------------------------- Capacity P Y -- ----------------- Type -------------------- Material---------------------- No. Compartments ................. Distance to nearest: Well -______-__________________________Foundation _____________________ Prop. Line .._.______._-__.______-ice LEACHING LINE [ ] No. of Lines _________ Length of each line---------------------------- Total Length --------- .............. G 'D' Box __________ Type Filter Material ___.____-___-_____Depth Filter Material ________________________------_•_-.-.__.. Distance to nearest: Well _______________________ Foundation ------------------------ Property Line ........................ V) SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ---------------------------- _-------•--_---Rock Size ------------------------_---- 17 Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... ;, io REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ______-_______-____-__________-___) c, Septic Tank (Specify Requirements) -------------------- ---------- ----- F ----------- Disposal Field (Specify Requirements) _______ /` ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- __ f (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: "1 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 '��Wo - --------- Owner ,�� 2 BY f ------------------------ Title ---- -.©'f i --- --- (If oerwner) FO DEPARTMENT USE ONLY oelAPPLICATION ACCEPTED BY ------ ----- ----- ------------------------------------ ----------------- DATE ------- `Q /----- ------- - ----- -- - -- BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------- ----------------------------- ADDITIONALCOMMENTS ----------------------------------------------------------- --------------------------------------------------------------------------------------------------- ------------------------------------------------------ ------------------------------------------------------------------------------------------------------------- ---------- ------------------------------------------ ---- - ---------- --------------- --- --- - - - -------------------------------------------------------------------------- ------------- - - Final Inspection by: ------ ` ' `' -��/ .,-------------------------------------------------------------Date - .� J` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M