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FOR OFFICE USE: APPLICATION FOR (SANITATION PERMIT (Complete p in Triplicate] Permit No. --------------- -----____-___-_ This Permit Expires 1 Year From bate Issued Rate Issued -1-.=S- -_ Application is hereby made to the San Joaquin Local Health D11 trict 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 . _.7-_ �--- ------CENSUS TRACT / -- -- ---- Owner's Name _ Phone �3- ;7 f-- - -- ------ ---------- Address -- Address ---------- ------ - 3- city Contractor's Name _.___ --- _--- h ; 7 License # l ----- Phone Installation will serve: Residence ❑ Apartment House❑ Commercial []Trailer Court ',❑ Motel ❑Other ----------------IM-------------------------- Number of livingunits:_--- /__ Number of bedrooms _____ � l�-o Gdrb ge Grander Lot Size_ - - --- -- - •------------------ ,._ .. _ Water Supply: Public�System and name ------------------_______ . - _-� Private ❑ ------------------------------------- Character of soil to a!depth of 3 feet: Sand'❑ Silt.(] Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ tHarclan _ .1 p ❑ ,Adobe ill Material -__-- -___ If yes, type _____________�_-____--_- --- IM .A. (Plot plan, showing size of lot, n of system-in relation to V; wells, buildings, etc, must be:placed on reverse side.) Q, � NEW INSTALLATION: (No septic tank or seepage pit permitte if public sewer is available.within 200 feet,) t e , PACKAGE TREATMENT,ySEPTIC TANK'[ I Sizel_l------------------------- - -F__---- Liquid'Depth ____.______________----- �� 4 aterial Capacity -- ----------------~Type ------- `` -, No. Compartments ------------ ......... Distance to nearest: Well ------------------ l---•-----1------Foundation ---------------------- Prop. Line ---------- --------- I - LEACHING LINE [ J No. ofaL nes -E------------ --------- Length of each line------------------ •------- Total Length -----------_--.----------- - 1 �I D' Box `------- Type Filter Material ---r-�----------- -----Depth Filter Material ---------I----------•-------------,-.--:.-.- Distance to nearest: Well -- -----_-"--�01!'Fou claition ---_ t---------------- Property Line. -----------------_.:._-- ' . F I 11L f 1 f SEEPAGE PIT [ ] Depth _ -_______ Diameter _______________ Number -----------------------------Rock-Filled Yes ❑ No ( , Distance of nearest. ---- --- + Rock Size ------------- = i s 44 ------------------- Prop. Line -------------- ' REPAIR/ADDITION(Prkv Sanitation,Perml.t# --------_____________________J-____-___--- E rest: e _ _ _______________________ Foundation Date=---.---------� Septic Tank (Specify Requirements) ----------------------- ----- ---F` . - -..- „ _ a - ---------------- f o - B' Disposal Field (Specify Requirements) _______- _ _ - __--___ --;-------_ _ Z ------__ '.. ' � -------- ------------------------ ---- { 44 _ IE ----- ---- ---- ------------------'------------------------ ---- <, - --- ' ' =f ` -----•T'Q- -- --------------------------------------------------------- (Draw------------------------------------------ / e i existing and required addition on reverse side) E I hereby certify that 1 have prepared.this.application and that, the_work_will be done in accordanie with San Joaquin i County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies tate following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation Ipws.1of,�Ca[if'ornia." i Signed --------------------------- --- ------------------- ----------------------------------- --------- Owner BY I ---- ------ Title ---------- Q � ( f other n owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---7--.p � ffr 3/ M----- ------------------------------------ DATE - ��_ BUILDING PERMIT ISSUED ----------------------------------- ------- •---------------DATE ------ ----- ----------------------------- ADDITIONAL COMMENTS -. I - ------ w - --•------------------------------------- -------------------------------------- -------- ------------- ---- )-----------••---------- ------------------------------------------ -- - - --------------------------- ------------II------------------- ------------------ Date-Final Inspection by: JOAQUIN LOCAL HEALTH DISTRICT I' E. H. 9 1-'68 Rev. 5M �