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FOR OFFICE USEµ {. *� .. .. ::. , ,. 'J APPLICATION-f0i'�5ANiTAT(ON PERMIT 1� ------------------- -:, Permit No: (Complete in:firiplicate) a - J --------------------_--------------_----------------------- - - Date Issued ---- ----------------- This Permit Expires 1 Year From Date Issued 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: f . JOB ADDRESS/LOCATION - !_ l :.c -� .....�'� "` � ------------ ---------------CENSUS TRACT __._S_`_-- 2=~-- / b £�----- Phone Owner's Name _ �" �-- .. Pone `' i ` -- : - -- n s e # Contractor's Name ___ Lice �! f� Installation will serve: esidence ❑ Apartment House-M Commercial :Trailer Court �❑ Motel ❑Other --- ^� I lfJ � ---------------- Number of living units_____________ Number of bedrooms ____________Garbage Grinder _______.__:Lot Size :Private`� Water Supply: Public System and name'___- Character of soil to a depth of 3 feet: Sand'[:] Silt Clay ❑ Peat ElSandy Loam ;' Clay Loam ❑ r 1 Hardpan ❑ Adobe•❑ Fill Material ------------ If yes, type ---------------- ----------- i ` (Plot plan, showing size of lot, loc.ation;of system in relation to wells, buildings, etc must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seep ggepit permitted if public sewer is available within 200 feet,) N ' PACKAGE TREATMENT [ ] SEPTIC TANK:[ Size-/ Liquid Depth -- ----------------•. -------- f Capacity -Type ''ss '` Material RNo. 'Compartment s --`_-------= Distance to nearest: Well _146-J---------------- -------Foundation -------- ------ Prop. Line------------- •=-;••-• . F LEACHING LINE No. of Lines ____.____-------------- Length of each line--. _ __-!t7�V1----- Total Length - s' = r D' Bax ---I------- Type Filter Material �� __ __.__Depth Filter Material ___________________ Foundation p Distance to nearest: Well __100------------ --------------- Property Line -----•------- --• •-•-•- � SEEPAGE PIT [ ] Depth _________ ------ Diameter ----------- ---- Number ----------------------------- Rock Filled Yes ❑ No .0 WaterTable Depth ---------------------------------------------..-Rock Size -------------------------------- 9 Distance to nearest: Well ----------------------------------------Foundation ___________:--_-_ -- Prop. Line _...____---.--------- .4t. REPAIR/ADDITION(Prev. Sanitation Permit# -------.------------------------------------ Date •-------------------------) Septic Tank (Specify Requirements) -------------------- -------------- = t Disposal Field (Specify Requirements) ---------------------------•-----------------------�- -----:--------,----- QW rot — - ' -------------------- -� ---------------------- ----------------------------------------------------- ---- .+ ----------------------------------------- -------- Ilh StlR ,o IR _ :t (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 w Joaquin fCounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: '" f "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." , Owner Signed Signed -------- ----- ---------------- -------------- � � ,� � Title . f BY �'-�i' '�y'a ------------------------------------------------ k ( other than owner) , , T k FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----""-'r`_13,-i� ---------=------ ------------------------- -------------------- --------• DATE ------------------- BUILDING ------2--J3- BUILDING PERMIT ISSUED ------------------------- -- -------DATE ------------- --------------- -------------- ---------- ----- ------ ADDITIONAL COMMENTS ------ ------- ------- - -- f ------------------------------------------------------------------------------------------ ----------------- ------------------- ----------- - � _ L -------- ------- ---------- -- -- ------ - --------- ---- - -------------------- --------- Final Inspection ------------ ------------------- a e I SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M -