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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT g_ Permit No. 9;' 5 `f� b5 (Complete in Triplicate) — ' ____ ________________________________ This Permit Expires 1 Year From Date Issued Date issuedf - f 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 with Cou ty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION --------- !_---l/Jr3------ - --- - -------------------------CENSUS TRACT --------------- ---------- Owner's Name __ ------- - ----- ------ -- -----------Phone�.7. . '�1� yL----- Address � ------------------------------------------------ , - - --------- ----- City [� _ --- Contracta�s Name ----____-- -- -- �Y�p---------- ------License # f 0( / ---- Phone W6 5�a7- Installation will serve: Residence ❑Apartment se-ED] Commercial{]Trailer Court i❑ �, / Motel ❑ Other --------------- -- Number of living units:_.--l�__- Number of bedrooms ___ arbf Grine __ ______ Lot Size _ _.. __,� ............... Water Supply: Public System and name ____________________ r , ---- Character, - i Private ❑ Character}of soil to a depth of 3 feet: Sand El Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe- Fill Material ____________ If yes, type __________________________ (Plot plan, showin t._ I of system (� p ! � g-size of lot, ocation of system in relation to�wells, buildings, etc. must be placed on reverse side.) [ NEW INSTALLATION: (No septic tank or seepage pit permitted Ifjpublic sewer is available within 200 feet,) PACKAGE-,TREATMENT [ ] SEPTIC TANK[ ] Size_____--7>.o^_______._____________________ Liquid Depth ________________________ tib _ Material-_----4 ----------- No. Compartments .................. .. L4 'Vt_ 1 ; Distance to nearest: Well ------------------------------=Fogridation---------------------- Prop. Line ---------'------,------ LEACHING LINE [ ] No. of Lines _______________________ Length.of-each line___---------f___ ________ Total Length ----------- ................ 'D' Box Y -_----- Type Filter Material =--------------------Depth Filter Material -----------------_-----------------........_ ' Distance to nearest: Well ________________________ Foundation ------------------I------- Property Line ____________,_.-__...... SEEPAGE PIT [ ] Depth ____________________ Diameter ______ _____ Number __._.____________._________. Rock Filled Yes ❑ No ID Water Table Depth --------------------------------------- ------Rock Size ----- ----------------------•-e- .Distance to nearest: Well-----------------------------------------Foundation :------------------- Prop. Line ------.--------------- tW REPAIR/ADDITION(PrevSanitation Permit# ---A- _.________________ Date ------------ ----------------- ------------- Septic ______.__. _________---- ) _________ Se tic Tank (Specify Requirements) i 2-- Disposal Field (Specify Requirement ) ----------- --- a let---s ----- ----------------------------------------------------- ------ ------- -- ------------- --- - - -------------� -- ---- ------- ------ ---------------- ------------- ---'---------------------------------------------------=-------------------------4--------------------------------------------------------------------------- ----------------------------- i - -- (Draw existing and required additi,on.on reverse.side) i i 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: t► "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 ----------------------------------- - I- Owner --------- - ----------------------- - BY - Title r / ------- (I of th wner) !- - FOR-DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- --- r":'--- -- ------- ------ . DATE --- ---- B G-P-------------- ---------- ---------------------------- -------------- BUILDING PERMIT ISSUED -- -- ----- ------ ---- --- --- ------- -- -�--- DATE ADDITIONAL COMMENTS __� 41A _1 _ _Gc••a cy,, ',`h+7�ti. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----- ---------------- ---- - --- A - - - - - - -Final Inspectionby ------------------------------------------------------------Date _�'a-�'� _l_------ -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M