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FOR OFFICE JUSE: APPLICATION FOR -SANITATION PERMITJ-----------------J----- Permit No. In.1-t---1:3(Complete in Triplicate) ---------- ---- --------------------------- ------------ � bate Issued This Permit Expires I Year From Date Issued ------------- ------------------------ t 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 . : --��------ f i CENSUS TRACT U V ` Phone - �� Owner's Name -------�---------- - - -------------------- -- -- ------ ---- ---- ---- ---- �------ - - -- Address ------- r`=fn----=- --- 1 ------------- City --- ------ -- ------------------- -----------.-_----- -------- i /1i Contractor's Name ------------------------ ----�----- ------'-- --.License #Wim, ----- .-_; Phone _V4-- F4 -------- Contractor's �IInstdllation will serve: Residence X Apartment House-E] Commercial :❑Trailer Court %❑ j .Motel-EA--Other" 1-=_- L w' a ' - Number of bedrooms _---_--•__Garba a Grinder <__ - lots -___- I �-- --49 �l-- ------------- Number of living units:------ --.- 9 r .�� .•, Wafter Supply:,Public System and name --------------------------------------------------------------------- -----------------Private ❑ Character of soil-to-a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam F _ a Hardpan ❑ Adobe•❑ Fill Material ------I-___ If yes,.tYpe --------------------%_ -- .s (Plot plan, showing size of lot, location of system in relation to- weli`s;°buildings, etc. must be placed on reverse side.) NEW INSTALLATION i (No septic tank or seepage pit permitted if public se fver,is avdiiable within 200 feet, PACKAGE TREATMENT { ] SEPTIC TANK S' e--'; �,y- r t c-- ,,.,1 �,:`-x Liquid Depth --- ------ Capacity�t0 Type No. (Compartments � r �� Distance to nearest: Well ----------- _------------1_, Foundation -----/_ r--__ Prop. Line ---------------------- LEACHING LINE No. of Lines ___"7�----------- Length of each line_'7P_J------------- Total Length df -------------- 'D' Box -- - Type Filter Material _'-_bepth Filter Material -----k�------------------------------- f Distance to nearest: We -- --=_--Foundation--.A) --------------------- Property Line -- --------------- SEEPAGE PIT [ ) Depth -------------------- Diameter ---------------- Number ----------------- ---------- Rock Filled Yes ❑ No i❑ Water Table Depth =-- -----------Rock Size -----------'--------------- Distance to nearest: Well-----------------------------------------Foundation !-----------___.---- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ------ ------------------------------------- Date ------------- .._--_-_---__-_-----) Septic Tank (Specify Requirements),, r ' � - --------------------------- ------------------------------- k Disposal Field (Specify Requirements) ----------------•--------------------------------------------------------`----------fi----------------------------------------------- ---- --------------------- i----------- ----------- -- ---------------------------- 4. (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: 4 I "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." a } Signed �...y -___ Owner # n f � �-------------------------- Title By ------- -- ------------- ---------------------------------- (If oth an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------------------------------------- DATE ------------------- BUILDING PERMIT ISSUED ----------- -------- ----- ---- ----------------------------DATE --------------------•---------------------- ADDITIONALCOMMENTS ---- - - ----------------- -----------------------------------------------------------=---------------------- -------------- --------------------`----------------- --- --------------------------- ------------------------------------------------------------------------------------------- --------------------- --------------------------'------------------------------------------------------------------------------- ---------------------------------------- --------------------------------- '- _:—__: __ - _ e --------- rte. : Final Ins e--c- b — - 'Date " p y. SAN JOAQUIN.,LOCAL 1-EALTH*-DISTRICT - t - F- H- 9 1-'AS Rev_ 5M