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FOR OFFICE USE: APPLICATION FOR-.SANITATION PERMIT ! . °� . �a' Permit No: - - ..{Com lete in Triplicate),-- ---------- - - --------------------------------------------- 2-7 ------ This Permit Expires 1 Year From bate Issued Date Issued s 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/LOCATION ___ _ I/__ __,. ._p__ r- -c I�- -- -------------------------CENSUS TRACT -----------------•---•---- Owner's Name -- l7° 11-- -------------- ----------------------------- -------------------Phone Address ---- utt/------- -- --------------••- I- C/- City Contractor's Name,-- ______ -E.-_--------- d-- ,. ,✓z- .License # S-_ __ _ Phone -43- '_._- � �Q Installation will serve: Residence_ eApartment House❑ Commercial :❑Trailer Court ',C] kMotel ❑Other -------------------------------------------- Number of living units:________ Number of bedrooms ________Garbage Grinder ------------ Loft Size __- GcC <►—_____________ Water Supply: Public System and name ------------------- ---------Private --- -- ---.�.--- - -- -.-._..1 Character of soil to a depth of 3 feet: i Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay,Loam.F] Hardpan—[:1 ,Adobe- ___________ If yes, type ______________________ (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,) �1 PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size---3ycy_1__i-__'!C__6'-------------- Liquid Depth ____ _ -7 _______ Capacity ----- Type ' t ----- Material__ CW� No. Compartments __` -.__...____-- ' Distance to nearest: Well _�--/=e20 "� ^ Fo ndation /�_"----------- Prop. Line -----.S~___________ LEACHING LINE [ ] No. of Lines Length of each lined Total Length -_- -G....:........ D' Box . _ Type Filter Material __�_ --________Depth Filter Material _-___ �1r_-----------------_------ _____ Distance to nearest: Well ---(4,-©----------- Foundation _- JO----------- Property Line. -__-5777..__-_.__- r SEEPAGE PIT [ ] Depth ____________________ Diameter _______-_---- Number ------------------------ --- Rock Filled Yes Q No Water Table Depth ------------------------------------------------Rock Size -------------- ' ' Distance to nearest: Well _______________________________________Foundation ______.__.___ ------ Prop. Line _________--_:__-___ F � - REPAIR/ADDITION(Prey. Sanitation Permit# -•------------------------------------------ Date ----------------------------------1 Septic Tank (Specify Requirements) ------- ------------------------------------------------------ --- -------- --------------_--...--------------------------- r Disposal Field {Specify Requirements) ----------: -----------------------------------------------------------•--------------- j. --------------- ---------------- -----------------------------------------------'----------------------------- ------------------------------------------------------------------ ------------------------ F ; -------------------------------------------------------------------------------------- - (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: 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 subiect to Workman's Compensation laws of California." Signed --------------q------- -------- Owner By � �1 �'`` ,c f Title ---------------------------------- ------------- ---- ---------- ----------------------------------------------- {If other than o er) i � FOR DEPART ENT USE,ONLY APPLICATION ACCEPTED BY -------------------------- ---- --- - ---- ------- - ------ . DATE ----� _`3l�= ��2'------------- BUILDING PERMIT ISSUED ----------------- ------------------DATE ------------------------ ------------------ ADDITIONALCOMMENTS -------------- --- --------------- -------------------------------------------------------------------------------------- ------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- ----------------------- -------- -=------- - Final Inspection b � _�'" __________________ H SAN JOAQUIN LOCAL HP. . STRICT E. H. 9 1-'68 Rev. 5M � 1