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FOR OFFICE USE: APRUCATION FOR SANITATION PERMIT - (Complete in Triplicate) Permit No. -------------- ----------- f: This Permit Expires 2 Year From Date issued Date Issued ' �/— Application is herebyopo ry�made to the San Joaquin Local Health District for a permit to construct and inst II the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _ { p,,,e. f _ �c�� - --'t-� CENSUS TRACT 5 Owner's Name - ----- {� a - ---------------------- ----- ---Phone -- ----- ---'1.�---------•--- Address 1 "67_eml ---- �---- -------- -------- Cit - ------------------------------------------------ y - �5C-------------------------------- Contractor's Name -_--�� --- ---------------- --------------------------------------- ----------License # ------- ----------------- Phone Installation will serve: Residence ❑Apartment House�❑ Commercial ❑Trailer Court :E]I Ir Motel Other __ �v±ti_ c.�-------- ---- --- Number of living units:-.-_ RC+ Number of bedrooms ---__---_--_Garbage Grinder _--__--- Lot Size --_ _--_"- ----------------------------- Water Supply: Public System and name • --- - --------I------------------------------------ Private aracter of soil to a depth of 3 feet: Sand'❑ Silt a' ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe [ it 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 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 ----------------•___-- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- ..-�§ 'D' Box ------------ Type Filter Material ----__ Total Leg ---- -- -- = -� - Depth Filter Material Length --------------- Distance to nearest: Well - -—�'- ``� '-� - ----- _--- - Foundation ------------------------ Property Line t, SEEPAGE PIT [ j Depth --------------------' Diameter Number -------------------------------------__---- Rock Filled Yes ❑ No C] Water Table Depth ------------------------------------------------Rock Size ------ Distance to I " nearest: Well Foundation Prop. Line ------------ ----- REPAiR DDITI pN(Prev. Sanitation. Permit# -------------------------------------------- Date ------------------------------- i tic Tank S ecif Re uirements) __--______________ • _ Disposal Field (Specify Requirements) - SX_I -X -----------I--- ----- ---- -----------------------------------------= -- # ----------- ------------------------ -------------------- ---- --------------------------------------------------------------------------------------------------- - _______________________ (Draw existing and requir-ed 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 i 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 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 sub' an's Compensation laws of California." ` Signed K.-------� _ -1 m ---------------------------------- _ Owner ---------------- BY ---------- ----- - -- - n -------------- ---------- Title -------- -------- ---------------------------- (f other than owned -------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --_.11_ __ 111,_ _ BUILDING PERMIT ISSUED --- - ------ - ------------------------------------------------- t DATE ------ --- ------ ---------- -- Di7lONAL COMMENTS -------- -----•-------------------------------------- - - DATE -- ---------------------------------------------------------- ----------------------------------------------------- ------------------------- _ A - = ---------------------------------------------------------------------------------------------------- _ Final Inspection by; -- _ _ _- �i _ ----_ - --- - -------- - --- - -------- ---.Date --- -- ------ ' SAN JOAQUiN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M C�"