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f FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. -------------------- _______________I This Permit Expires 1 Year From Date Issued Date Issued ' _ 0._"""". 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 Rule .acrd-Requlotion s: I JOB ADDRESS/LOCATION ------ ------------------------------------ ------CENSUS TRACT -.-----------__-• Owner's Name _.Off A -_"_""CZ {�y e Address _k-1,571 ,-A _ ------- •--. City F - - ---------------------•----------------- Lf Contractor's Name ------License # ;ZsS/�_ .J- Phone Installation will serve: Residence)<Apartment House[] Commercial ❑Trailer Court :❑ i Motel ❑ Other , Number of living units:__. -___-__ Number of bedrooms ___/-----Garbalge Grinder _ Lot Size -----�- --........ Water Supply: Public System and name ---------------------------------- ----------------------- _____Private t ----------------------------------------------- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ ClayL Loam ❑ F Hardpan ❑ Adobex Fill Material _V(3 _ If yes, type ____________________________ t (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 TAN Size_ as" _1 ------------ Liquid Depth 7__________________ Capacity S f� ________ Type _______ _;d __ Material_ -_ Nod Compartments t_--_nem-_.---.._- Distance to nearest: Well - -�____________________•_____Foundation _, C_____-__-____ Prop. Line_i�___ cr ' ' LEACHING LINE No. of.Lines ______ ____------------- Length of each li e__-- ._________.___-- Total Length :___- Q_ - D' Box _.®---___ Type Filter Material __ (,%Depth Filter Material ------ _----: _ - -------- - � { Distance to nearest"Well ___ _---____f-_-__ Foundation,.__ _______________ Property Line _ ___ __��• '. SEEPAGE PIT [ ] Depth ____________________ f7iameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 Water Table Depth --------- ------------------------------------Rock Size --------------------------- Distance ---------------------- --Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# _____-.--_.____._________________________ Date ---__________ Septic Tank {Specify Requirements) ------------ ----------------------------- -- " Disposal Field (Specify Requirements) ---------------------------•---------------------------- -------------------------------------------- ------=----- = ------------------------------- I p } f- t $..r x -------------- d .- -. .(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 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 f the work for which this permit is issued, I shall not employ any person in such manner as to be rrne su .je�ct to orkm n47) 's Compensati.o ws of California." Signed ------�" - _ _ - -------------------- Owner E BY --------------------------- Title'F :. ---------------------- ------------------------------------ (If other han,owner i _ f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTER BY -- ----�--- -- ---------- -- - -"-"--- DATE ----�°� 31 �o --------- ---- B BUILDING PERM17 i5SUED - ---------------------------------- --------------DATE ----------- ----- ADDITIONAL COMMENTS ----- �= - - ------------------- ---------- -------------- -------- ------------------ -------------------------- --------------------- -- ------- - ------- ------ ----------------------------------------------------------------------- --------=------ -------------------------- --------------- -------------------------------------------- N. Final Inspection b - """ " "" p Y ------------------------------------------------------------------------Date SAN JOAQUIN LOCAL HEALTH DISTRICT I E. H. 9 1-'68 Rev. 5M z ��