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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 6S-771 CJ g p�--Ili�* - -- - --- - - Permit No: .I� �Q_ (Complete in Triplicate) - - Date Issued _.l_._- ------------_--- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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/LOC ON # 71 -------------------- -- -------- -- CENSUS TRACT Owner's Name ------ -------A---- ------ i -------- a Phone --- ------ ' ------------Address .---- ---• ----- ------ City --- f- ----------------------------------------- -•--•--- Phone ---- -- Contractor's Name d License # a Installation will serve: Residence []Apartment House ❑ Commercial :❑Traller Court i❑ E`�*--� �- i Motel ❑Other -------------------------------- Number of living units:_____r✓_--- Number of bedroomsGariiage Grinder _yg-S_ .Lot Size _____"____.___---________________________ i Water Supply: Public System and name -------------------------------=---- ---------------------------_-- ------------Private Character of soil to a dept th of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam I Hardpan J� Adobe ❑ 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.) NEW INSTALLATION: '{No septic tank or seeps a pit permitted if public!ewer is available within 200 feet,) PACKAGE TREATMENTSEPTIC TANK' Size !s or �'y _____________ _ ___ Liquid Depth -- ___ _____-________. � 1 E Capacity -1'- c-o __ Typ --------- Material____._____ _ No. Compartments ------ .__. .-. istance-to--Weare t: Well --------:---------------------------Foundation ---4-b-----`------ Prop. Line --5-__---_-;----•- � LEACHING LINE [ No. of Lines _r__._. g � � -------=----- -------- -- Length of each line------�a________________ Total Length ------____ 'D' Bok __t _ ype-FiIter A&dter161 -----_�_}__l�_---_Depth Filter Material -- _ I Distance to Nearest: Well ____________ _S----!_------ Foundation ------ Q--r ---- Property Line -- ------------ ---- t � SEEPAGE PIT Depth I f -- Diameter _______________ Number ----------------_------____ Rock Filled Yes [] No i0 [ ] p Water � ,. ri , Table,Depth ------------------------------ --------Rock Size -------------------------------- Distance-to nearest: Well _______________________________"________Foundation -------------------- Prop. Line -_-------._--_--__.___ REPAIR/ADDITION(Prev. SanitatioWPermir# -------- ----------------------------------- Date ---------------------------_------I I SepticTank (Specify Requirements) --------f--- ------ --------------------------------------------------•-----------:----------------•r---------------------------- Disposal Field (Specify Requirements) '"----=---------------------------------------------------------------------------------------------------------- --------------- i - .% 'F _ _________________________________________S_____----------3� .______2�_______- _-________-____.__-_________________-__-__-----.----- -----.-______-____________________-___________-_- } (Draw existing and required addition on reverse side) r 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: "1 certify thaf in t performance of the work for which this permit is issued, I shall not employ any person in such mne anr as to become su je t to Workman's Compensation laws of California." f > Signed �- ---------`�- ---------�------- --=- ---------�---�Y � :Owrter ��. BY ------ -------- .�—in.., ---------=----. Title ' f other than owner)-. , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------ DATE BUILDING PERMIT ISSUED -------------------------------------------------------------------- ------------------- ----------DATE ------------------------------------------- ADDITIONALCOMMENTS ----------------------------------------------------==-- ------------------------------------------------------------- ------------------------------ ------------At -------- ---------------------------------- ------- ----- ------------ ---•------- - ------------ ------------ -- ---- -------------------------- f� ------- Final Inspection by: . --------------------------------------------------------------Date {l.---y� - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ~