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FOR OFFICE4-USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: 5:56---- p +� itr i OPVA '` "This Permit Expires i Year From Date Issued Date Issued _ 1_L __:- 1 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/LOC N -- ----- --- ---- ----------------------------CENSUS TRACT -------------- ------ Owner's Name ---- -- - ----- --------- - - - --Phone ------ Address ---------------- ----- - City Contractor's Name ------------- --- V------ --------License # /Q_Q ---- Phone Installation will serve: Residence ❑ Apartment House❑ Commercial❑Trailer Court '❑ Motel ❑Other Number of living units:....I----- Number of bedrooms _______Garbage Grinder ------------ Lot Size _---__ Q________________________ , Water Supply: Public System and name __- ______________ Private Character of soil to a depth of 3 feet: Sand'[] Silt❑ Gay ❑ Peat❑ Sandy Loam -❑ Clay Loam_❑ I Hardpan ❑ 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.) rt 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. Comparfinents r Distance to nearest: Well _�-s______________________________Foundation --__-___E________-___ Prop, Line ______---------____.__ LEACHING LINE { ] No. of Lines ---------------/ Length of each line---------------------------I Total Length -------------- ------ -_.-..... �Q 'D' Box ----------� Type Filt e� Material --------------------Depth Filter Material•IS__IA---,-------- ------- .............. Distance to nearest: Well ------------------------ FF ndation --------------r------- -- Property Line _:_______._____.__...._ SEEPAGE PIT [ i Depth ------------ ameter ---------------- Number -----------___--_ ---__-`-- Rock Filled' Yes ❑ No o Watef-�Table Depth = -------------------------------------Rock Size -----= ------------------- ! flstance,to nearest: Well A--------------------------------- --Foundation ----------------- p _......---r --------- REPAIR/ADDITION r (Prev. Sanitation Permit#________________________''-'�, Date Septic Tank (Specify Requirements)(_.-->----- --- r ; - ------- ----------------------- - Disposai Field (Specify Requirements} -----------+ --- ---• - __ -- - ' / �i r- , l i 1 -- : a� a= ------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------- i (Draw existing and required addition on reverse side) I hereby certify thati1ave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,(State Laws, andlules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: ag A "I certify that in the performance of the work for which this permit is issued, I shall not employ a y person in such manner as ta:become subjectfto Workman's Compensation laws of California," Signed =-------- V-------I-------------------------- Owner - --- -- - -- -- f _ BY ---------------- = ------ Title ---------------- --- ' {If other tho o ner) - - _ --------------------------- il FOR .DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY i --------- '- - ---------- ------------------- ------ ------------------ -------------. DATE --------- --J!670 BUILDING PERMIT ISSUED --------------- �" - ------------------------DATE ------------------------------------------- A DITIO COM ENT si^'` '' ------- 1 ------- - - ---- -- '1- 4 - -------- ci -- -------------------------a-,_A -1%-_b°1 -( - ------ ------- - ----------------------------------------------------- - -------- Final inspection by: ---------- ------ Date -------- --- T SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M