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FOR OFFICE USE: PPLICATION FOR SANITATION PEIT t�- (Complete lin Triplicate) Permit No. . ��5 --------------------------------- _--------- ------ This Permit Expires 1 Year From Date Issued F I L 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 _ ` ------- -------.-CENSUS TRACT ��._....._. Owner's Name ~"- --- - ------------------( -- ----_------------ -----Phone ------------------------------------ Address ------------------ -- -------------------------_ -------------- City --- ------------------------------------ Contractor's Name ---- ---- ----- > k-_.License # JJV.3 Y Phone - --- Installation will serve: Residence [!(Apartment House-[] Commercial:❑Trailer Court s❑ MotelE]Other --------------------- • -------------------- Number of living units:--.---(----- Number of bedrooms _!;�-------Garbage Grinder __ Lot Size _lS ------------------ Water Supply: Public System and name --------------------------------------------------- ----- -----------------Private [7�f Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam {'� Clay-Loam.❑ Hardpan ❑ Adobe-❑ Fill Material ------------ If yes,type --------- ------------------- (Pl'ot plan, showing„size„of.Jot, location.,of syttem in relation to wells, buildings, etc. must be placed on. reverse side.) I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[.] ,� Size------------------------------- ---------------- Liquid Depth ----.--------------------- Capacity TyPe =--- --------- ---- Material---------------------- No.: Compartments --- ------ Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------------:,.------ V1 LEACHING LINE [ ] No. of Lines ----------------------- Length of each line------ ------------------... Total Length 11------ 1 Distance' Bo to neareyp Weller Material .............Depth Filter Material --------------------.------------.---------- ---- Foundation ------------------------ Property Line --.------------•--.-_-- SEEPAGE PIT [ ]' Depth _- -- Diameter ----------- ----- Number ---------------------------- Rock Filled Yes ❑ No :0 Water Table Depth .------------------------p---=--------------------Rock Size -------------------------------- Distance to nearest: Well -----_-..._...M.... ..................Foundation -------------------- Prop. Line --------------- REPAIR/ADDITION(Prev. Sanitation Permit#-=-._ : =------------------------------------ Date -_------------.._.----------------J Septic Tank (Specify Requirements) ----------------- -- ----------------------=-- ------------------------------------------------------------ -- Disposal Field (Specify Requ'remen } o- ,, -IL --- c� i,--------- - ------" ----------- In ----- --------------------------- ------------------------------------------------- ------------------------------------------------------------------- (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: :; "I certify that in the performance of the work for which this peemit is issued, I shall not employ any person. in such manner as to beco a subject to Workman's Compensation laws of California.” 'Signed ---- = ------.----- Owner a BY . ' [�Com- `- ------- ---------- --------------- Title ----.020LJolL L� (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B ---- ---- ----- - DATE ----- BUILDING PERMIT ISSUED -- -__.::_.- _DATE _: - _ = ADDITIONAL COMMENTS - -------------------------------- ----------- --- ---------------------------------------------------------------- --------------------------------------------------- ---------------------------------------------------------- - --- - -------------------- --------- ---------/ ------------------------------------------------------------------=------------------------------------------------------------------ ------------------------- -L. - ----- -� ------ Final Final Inspection by: ------------- ----- ------------------------------------------------- -------------------------------------Date ----- ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M