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k 1-FO'R OFFICE USE: r APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: - :7� li rf �!___. This Permit Expires 1 Year From Date Issued Date Issued 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 Co ty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC N �Ef ,-- • ------------ -CENSUS TRACT ------------------•------- Owner's Name ------ / ---- --------- ------------------ Phone Address ----------------- -----L :' --- - - ------- ----- - -----A At. Cit Contractor's Name - G ----------- ----------- -�— - ----- -- - License # _/W3----------- Phone ----------- -------•-•• ------ Installation will serve: Residen eApartment House,E] Commercial ❑Traller Court ;❑ Motel ❑Other Number of living units:------'1-___ Number of bedrooms __: ------Garbage Grinder -----------. Lot Size ______: --'-e ___________• Water Supply: Public 5yste lfil and name ------------------- -------------------------------------------------------------------------------------Privateo Character of soil to a depth fof 3 feet: Sand ❑ Silt❑ Clay .❑ Peat ❑ Sandy Loam ❑ Clay Loam:❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK Size__I_`� S 1 .` - •------------ Liquid Depth -- " :•• ` Capiacity1L? �-1`- TYPE ----- Material-_ No. Compartments __ a- ,_....:..__ ~ Distance to ne rest: Well -------- 1 -l-----------------Foundation ----Ai Prop. tine �_/--•----- LEACHING �•.I: LINE No] of ILines ------�___________ Length of each line----f- �_ ------ Totai Length �� • ........ I D' Box __1_______ Type Filter Material �___-_Depth Filter Material ____/, _ ______ __ ..:.... M ------ Distance to nearest: Well ___________________ ___ Foundation ---__._--_-__-_______-- Property Line __-__- SEEPAGE PIT -►� pt ' Z [r Depth V biometer ________________ Number -_.__.___-.-___-_____-___ -Rock Filled Yes J No Water Table Depth �lU Rock Size ___-1 i 'x_3_�, P ------- �`-- ------- -----------=--•--- f ---------------------- Distance ------- Distance to nearest: Well ----------�_42 -_�------_---------Foundation '-_le)---- ------ Prop. Line ... ____ --------- F� i REPAIR/ADDITION(Prev. San litation Permit# -------------------------------------------- Date ._-------------••-----------------_) Y Septic Tank (Specify Requirements) -----------------------------------------------------------------------------------•-------------------------_, �. Disposal Field (Specify R`quirements) ----------------------------------------------------------- J ------------ ------- I - -------------=---- --------= ---------------------------------- ---•- hereby cerci that I have I re orad this existing cation an"fiat h__-tion____________--------- � _ • dition on reverse side) y P P PR a work will be4done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Re ula 1 ns of the San Joaquin Local Health District. Rome owner or licen- sed agents signature certifies!�the following: "I 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 subject to Workman's-Compensation laws of California." Signed --------- --------------- I� ��l 3 Owner BY --------------------- 1JLtLG.� (�. c_,` ,� :. --------- -- ------------- Title'- LIS�hL -C�ic --------------------------- (If other than afwned � - . I•,. I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYI`; ---------- ---------------------------- DATE --�'`7___��----------------- BUILDING PERMIT ISSUED ---l-------------------- ------------------- --------------DATE -------------•-------------- ADDITIONAL COMMENTS ----I_------- .Il, --------------------------------------------------------------------------------------------------------- -----------------------------------------------il----------- -------------- -------------------------------------------------- -- ----------------------------= _ Final Inspection b Date/' -. - -------- ------------------- ------------------------------------------- SAN ------- - -- ------------ ----- ------- - ff SAN JOAQUIN LOCAL HEALTH DISTRICT E. H,_9 1-'68 Rev. 5M