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FOR OFFICE EJSi:: APPLICATION FOR SANITATION PERMIT Permit No // •- .......r_.......---•-.........-•........................ ' . .'e�:.fp� tComplete in Triplicate) .....�................................................ - Date Issued ..................I.... ../....�/✓:7�. . This Permit Expires I Year From DoH lssued 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/LOCATION &V4_1......; Jz�?.c iz -=: ; _. '... .............................CENSUS TRACT .....I.................... Owner's Name ............... - '� �4 x--•• F Phone . � --.. .. .. .... ................................... Address ............ � ..._. 7... .... ...... /., (�... ._.....City .... = ...`-'? ............... ........................_ r �� Contractor's Name -- . - - ... .a�z;.._.._.Licenae � .... ...... Phone .................. Installation will serve: Residence 0 Apartment House Commercial[)Trailer Court 0 Motel ❑Other. Number of living units:--_..r...._ Number of bedrooms ..?...Garbage Grinder ............ Lot Size ............................................ Water Supply: Public System and name -........................................................_-........---.................._............,:......Private (� O Character of soil too depth of 3 feet: Sand o Silt o Clay o Peat❑ Sandy Loam.O Clay loam p O Hardpan�/ Adobe o Fill Material ............ If yes,type............... ............ (Plot pian, 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,l PACKAGE TREATMENT [ ] SEPTIC TANK] ] Size-................ ............................. Liquid Depth .-........................ r Capacity .. Material:-•.................. No. Compartments ...................... Distance. to nearest: Well ....................................Foundation .................... Prop. Line ............:......... LEACHING LINE [ ] No. of Lines ........................ Length of each line_._........................._ Total length .........--._..... ......... 'D' Box ....--_ .... Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ........................ Foundation ........................ Property Line ..................... SEEPAGE PIT [ I Depth -_---------_----- Diameter ................ Number ..__....._•___..... ........ Rock Filled Yes 0 No 0 Water Table Depth -------------------------------------...........Rock Size ................................ Distance to nearest: Well ........................................Foundation ....................:Prop. Line ...................... R EPAIR/ADDITION Wrev. Sanitation Permit# ...........................•---_...._.._..-- Date ...........-.................... } SepticTank (Specify Requirements) --••-- -------------•-•-- --------- .......................................--.......................................................... Disposal Field (Specify Requirements) --•-••---.....--•--•..............rte---•• .. ..._..............._...-----------•••-- ................. !L• --- -t '. -- ----- - ........ " ............................................... {Draw existing and required addition on reverse side) 1 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: "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 laws of California." Signed .......................................... •--- -•-----.. ..... Owner -_._ . By ...........................------------_--------..._ tirst�� -._' _ `...`z�;)k Title � -?--�'�� ..... (If other than owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- -- -• ......................••-......----• -------------------------------------- DATE ..-��2'�'-.�76. ..............--- BUILDINGPERMIT ISSUED .---•...................... • •. -- --• ............_..__......-------....._.. .......DATE ........................................... ADDITIONAL COMMENTS ........................................... Final Inspection by: ..--- Z,�. -----Date .7��.7�.......---................ + EH 13 24 1-68 Rev. 5mr SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M