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FOR OFFICE USE: ^�s�.ORter---------------� d� APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. -_W__ ----7777-- 7777- - - -- - - --------7777-- This Permit Expires 1 Year From Date Issued Date Issued 4a_6 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 com fiance with County Ordinance No. 5A9 and existing Rules and Regulations: JOB ADDRESS/LOCATION _ -----------_ '� � _- _/_ _ /- Qf�r �� C� <1J4 ---CENSUS TRACT --•---------------------- Owner's Name / -- i ------------------------------------------ --------------------Phone ?_ _$.. ------ �� Addressr---- -7777-• ----------------------------------------7777•- - CitY ------------------ Contractor's Name -. ------------------------------------------------------------------License # ------------------------ Phone ------------------------------ Installation will serve: Residence ❑Apartment House°0 Commercial Trailer Court Motel ❑Other -------------------------------------------- Number of living units:------------ Number of bedrooms _________Garbage Grinder ------------ Lot Size _o __ ____________________________-__ 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 ---------------------------- �L (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) c}` NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is ava/`ilable within 200 feet,) �] PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----A�Q ___--- .��___!__--------- Liquid Depth ---------------------,----- Capacity -------------------- Typer ::7_ Material --"----- No. Compartments -----------------_-- Distance ---- ------.--_.Distance to nearest: Well _f, 'O___C --------------Foundation ----nO----------- Prop. Line _rQ______________ LEACHING LINE [ ] No. of Lines ---_---------------- Length of each line----- --------------- Total Length �7-6�___________________ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------_----------_-._---__---- Distance to nearest: Well _I11P---�_T Foundation ________________________ Property Line SEEPAGE,PIT [ ] Depth Z 5--------- Diameter ---3_3------ Number --------/_ .---_---_--. Rock Filled Yes No i❑ i Water Table Depth 7777777 ........... Rock Size ---2--- -------------------- - - - - --7777•- -- -• Distance to nearest: Well _/ Q___F_�_________-_Foundation _!a_ __r_T rop. Line A_� ..... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ----------------------------------------='---------------------------------------------------------------- --------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------ ------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 sub' c o Workm n's pensation laws of California." Signed - i� lh�!1�- Com' ----------------------------- Owner By ------------------------ ------------------------------------------------ ------- --------- Title ------------------- - - --------------------- -------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y ------------------------------------------------------------ DATE Z 9------------- BUILDINGPERMIT ISSUED -------------------------------- -----------------7777-- -- I --- --------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS ------------------- - - ection b� d , Final Ins - ti +,�--��;�,-- - -{' �r7777- - -- 7777 ---777777 77-7777-- -- - - -- -- - -- - --- -- ------------------------------------ PY= --------------------------------------------------------------------=--------------------------------- ---------------Date ------------------------------ --------- SAN JOAQUIN LOCAL HEALTH DISTRICT ` ir}— 1$- 6c{ E. H. 9 1-'68 Rev. 5M (C b� rw,3", / � ?�t \�)