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FOR OFFICE USE: ; APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ":7_Z_' 5 0 ----_ ----- This Permit Expires ] Year From Date Issued Date Issued __-ZL_-�-L Application is hereby made to the Sa Joaquin Local Health District for-a permit to construct and install the work herein described. This application is made i compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/ �N .__19 __ � �CENSUS TRACTOwner's Name -------Phone Address -�- - Cit _ Y t Contractor's Name ------ c.eQ.eJ_- -�-- -- ------ - G� '-- ,----------License # l- � ---- --------- Phone --------- -----------------•-- Installation will serve: -Residence 0 Apartment House 10 Commercial ❑Trailer Court ❑r Motel ❑Other Number of living units:----1------ Number of bedrooms _j------- Grinder _.-_----_--- Lot Size - _-.--� '- - ____-- ---_ ---- Y �------------------------------------------ ---------------------' {---.Private Water Supply: Public System and nameFl- Character of soil to a depth of 3 feet: Sand'❑ "Silt l] Clay ❑ Peat❑ Sandy Loam" Clay Loam Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type -----------------I 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 [ ] Size'-----=--------------------------------------- Liquid Depth ----------- Capacity --`------------------ Type -------------------- Material I--------------------- No. Compartments --------------------- �p Distance to nearest. Well ------------------------ ---- ------Foundation ---------------------- Prop. Line ----------------_----- LEACHING LINE [ ] No, of Lines ------- ----- Length of each line." -----------------_.-__ Total Length ---------------------------- 'D' Box __-- ------- Type Filter Material ____________________Depth Filter Material -------------------- ---------- Distance to nearest: Well ------------------------ Fou_ndation ------------------ Property Line ' [ 1 Depth ----- SEEPAGE PIT F--------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ElNo ❑ Water Table Depth ----------------------------------- --------Rock Size -------------- Distance to nearest: Well ------------------------ -------------Foundation ---------------•---- Prop. Line _--------------- --- REPAIR/ADDITION(Prev. San itation-Permit#`7--- --__--_---------------------------------- Date _---------_----__.--_- -----------) Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) _._-_--_- -- -- --- ----- --------------------------------------------------- �- S0 Z-- '-�-�- " `ems --------- -------P`---- - -- ------------------------------------------------------------------------------------------------------------------- {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 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�'Compensati.on laws of California." Signed ----------------------------------- ----------- Owner G - - ----------- ----- --------- -------------- - BY ------ ----------------- -------- ------------------ � �� Title .. (If other than owner) - ---------------- Ar FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- - - _ -_ --------------- -------. DATE- ------'-- - ---- ------ -- - -------------------------------------- BUILDING PERMIT ISSUED --- ------=------------ DATE ------------------------------------------------------------------ ------------- TIONAL COMMENTS --------- ----------------------- ------ -------------------------------------------------------- ------------ ------- Final --------- --- V --------- ----------------------------------------------------ina fns action b p Y Date -SAN JOAQUIN LOCAL HEALTH DISTRICT F. H. 9 1-'68 Rev. 5M _ '