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FOR OFFICE USE: �,� APPLICATION FOR SANITATION PERMIT /---� ------------------ � �� n Permit No. ------ ----------- O�-�4 (Complete in Triplicate) ' Date Issued _e�fT=,/d� `. ----------______------------------------------------------ This Permit Expires T 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LO TION -------ee------- �KJ�r --- -----, -- y ENSUS TRACT -------------- ----------- Owner's Name L /..LGrt�2;+� Phone -V64---�z z ------ - - -- -------=------------- Address ----------------- City ------------------------------------------- Contractor's --- - - - - --- - ------ -- - - --- ----- -- - Contractor's Name --------------------fl?a� ---- ---------------------------------.License ------ Phone Installation will serve: Residence (Apartment House f-] Commercial [-]Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:________ Number of bedrooms __,j_____Garbage rinder __ ______ L t ize :_._ x` ___.___.__._..._ �� _ ._ Water Supply: Public System and name -�----------------------------- ---------- --------- _-- __"`_'_-::_------- ----Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat.❑,, Sandy Loam •❑ Clay Loam '❑ Hardpan ❑ Adobe Fill Material _.__________ If yes,type __.______________________ (Plot plan, showing size of lot, location-of system in -relation to wells, buildin gs, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is ava� ilable within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size__ --------------------t________-_-___.____ Liquid Depth ._____________-_-,_____ 1%J r Capacity -- Type -------------------- Material---------------------- No. Compartments ----------------•--•-- Distance to nearest: Well -------- °-___'________I-------------Foundation ---------------------- Prop. Line ---------------------- r LEACHING LINE ] No. of Lines ________________________ Length of each -line-4____.________-_._.______ Total Length ______________-__--__--_-__ V 'D' Box ------------ Type Filter Material ------F-----_------ Depth Filter Material ---)----------------------------------------- Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ____________•__-__.__.__ SEEPAGE PIT [ ] Depth - ----- - --------- - Diameter ______r�`: Number.-_- _____________________ Rock Filled Yes © No C] - - - Water Table Depth --------------------------------------------------Rock Size ______________________ Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop-.Line ---------------- REPAIR/ADDITION(Prev.(Prev. Sanitation Permit# ___-___.._-_-----_-------------------------- Date _________________I____________) Septic Tank (Specify Requirements) ' : ri Disposal Field (Specify Requirements) --------- - ---------LI --------------------------------- --------------- ------------------- ---------• = - -------- ,..._ �. ------------------------------------------------------------------ (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 Dasfr'ic`t. 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." Signed ------------ - - --------- ------- -------------- ---------. Owner BY ------ ---------�fother - - -------- c Title - ------ - t ( tha weer]-- - - -- �- - -- — --- m Fb 14 OR DEPARTMENT USE ONLY APPLICATION ACCEPT D BYDATE ---- R- ----- ------------------------------- - BUILDING PERMIT ISSUED ------ - ------------------------------------------ -------DATE :.-------------------------------- - ADDITIONAL COMMENTS ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- --- - ------- ----- >-r ' ------------- ------ ---------------------------------------------------------------------------------- ------- - Final Inspection by: f --------------------------------- -- ------ ------ ---------------------------------.Date ----- --'-- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M