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FOR OFFICE USE: "PLICATION FOR SANITATION PERl11.06�r -- ... ............ . - Permit No. ...... .-.. (Complete in Triplicate) p ---------z -- ------------------------------- -- 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: JOB ADDRESS/LOCATION 3� / -----------------------------------CENSUS TRACT -----------------_-.---- Owner'sd . / ------------------Phone ------------------------------------ ------------ 11 "< - a ----------------------CityAddress e - _ 0 Contractor's Name ------ - --ru,x�__tRw . . it-- - .License # t;7 Phone Installation will serve: Residence[q A artment House❑ Commercial❑Trailer Court C1 Motel ❑Other Number of living units:----- Number of bedrooms .��____--Garbage Grinder _-._..._._ Lot Size ___� ------------ ------------- Water Supply: Public System and name -------------------_ _-- ------ -------------------Private [ Character of soil to a depth of 3 feet: Sand 0 S, ❑ Clay ❑ Peat E] Sandy Loam ❑ Clay Loam❑ Hardpan Adobe o Fill Material --------- - If yes,type _____________________.__ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) L NEW INSTALLATION: (No septic tank or seepage pit permitted if-public,sewer is available within 200 feet,) LM PACKAGE TREATMENT [ I SEPTICTANK[ ] Size--------. -------------------------------------- Liquid Depth -_...__.-.-.___,.-_. Capacity ------------------ Type,--------- ---------- Material--------------------- No. Compartments ` 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 . __..____-_...__....__.---------------...- Distance to nearest: Well ------------------------ Foundation -------------- --------- Property Line ...___.....___---___ \ SEEPAGE PIT [ ] Depth Diameter ---- ----------- Number ---:-_-:,___...__-....... Rock Filled Yes ❑ No ❑ Water Table Depth ----------------------------------------------Rock ¢e .....---------------`--- Distance to nearest: Well ___.._____..____--_____.............Foundation ......._____-_-._ Prop. Line LREPAIR/ADDITION(Prev. Sanitation Permit# ..................__-.---------------.--- Date ---__.------------_-----------I Septic Tank (Specify Requirements) ------------------------- - --------------- --------------- --..---------------- ------------ _ - -- Disposal Field (Specify RequireKnents) ----------------------�--�----- -------------------------------------- - �-C -- -- — F� �COiS o� .� � ---------------------_..---'_-- •- -' - ------ --- -. _ 1 ----- --- ---- --x- -' - ------------ -' -----------'----------------------------------------------- L (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: L "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." Signed -------------------- - - - ' - - Owner LSitle _ 1 s c �---------- ------------------ 4 FOR other than owner) FOR DEPARTMENT USE ONLY LAPPLICATION ACCEPTED BY - ------------ --------- --- -------------- ......._------------- DATE .�-Y3 =v`9---------------- BUILDING PERMIT ISSUED ------------------ -- - -------------------- ----_-------'-------------_-----------DATE ADDITIONALCOMMENTS --- ------------- -- ----- ---- - -------------- -'-------------------------------------------- -------------------------- ------- ------------- - - Final Inspection by: ------ -- ---------------------------------------------- SAN - ..-----'----------------__.Date ---- � - ---�---SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M