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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT -- - -------- --------- - ---------- ------ �C1-"":�-!,G_- (Complete in Triplicate) Permit No. ---------- ----------------- - ------------------ ----------- 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 const* ct and install the work herein described. This application is made in compliance with f County Ordinance No. 549 and ex sting Rules and Regulations: JOB ADDRESS/LOCATION .--- - `_fid_----- --- �C�-�- --------------- NSUS TRACT ------- ----=-------- Owner's Name 4 -------------------------------------- - ----- Phone - Address ------------1 av --- City Contractor's Name ------PO R-F 1"S 1--}----------- ---------------- ---------._.License # -- -------- Phone =' ---------- -- ----------- Installation will serve: Residenceyj Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other Number of living units;--- --- Number of bedrooms '7v--Garbage Grinder Ad/�)--- Lot Size -____ -- Water Supply: Public System sand name ------____--_------------------ ---- --- - rivate �iI_w ptl feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam • Clay Loa i Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type --------------------- ----- (Plot plan, showing Size of lot, ocation of system in relation to wells, buildings, etc, must be pla on reverse side.) NEW INSTALLATION: {No septi tank or seepagermitted if public sewer is available within 200'6e PACKAGE TREATME T [ ] SEP ICT/ T. ize----------- �--x/- --------------- Liquid , e4th ----- r---_"-_-- Capacity . -[rte- Materia!_ ___ -- No. Comport n sG Distant, to ne st- II -- ' �, --- - - ------ ------- - oun ion 010q-/O-------- Prop. i e - -----•------ ...._ LEACHING LINE [ ] No f,L�i� - --- ------------ ength of i . --d+-s --- _- ---- Total Length - D--- -----_---•-- :- D' Box -----_=_�__�Type Filter ria _ .-----De ..Filter terial - ----- -- ----------------------- Distance to nearest: Well -----'-- -------------- Foundation ----------- ----------- Property Line ------------- _-------_ SEEPAGE PIT [ ] Depth -------------------- Diamet ---------------- Number ---=f .-_---------------- Filles © No I❑ Water Table De th ------------------•---- --.Rock -ize Distance to nearest: Well --------------------------------------- Foundation -------Prop. Line ---------------------- REPAIR/ADDITION{Prov. Sanitation Permit# -------------------------------------------_Date --_--__--_._----_--- Septic Tank (Specify Requirements) --------------- -- - -------- ----------------- t)`' ;"` Dis o d (Specify Requirements) -------- ------ ---- `Qf T -------- U'uP qt`... 14, �. ------��-b sU►yrn� N. c- --` ------ - ----- 3Q�C` ' - 'd r� (Draw existing and required 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 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�r ` "I certify that in the performance of-the work-.ve:-whrch.this-p:erm t is.-,ssued,sl_shall..not_-employ.anyxperson in such manner F as to become subject to Workman's Compensation laws of California." Signed ------------------------ - ------------------------------------ Owner BY Title (if of an owner) FOR DEPARTMENT USE ONLY` APPLICATION ACCEPTED BY M1 '�-------------------------. DATE -----I -�� E� --------------- ' BUILDING PERMIT ISSUED ------'---- ----------------- ------------ ------ ---------------------DATE ------------------------------------- ------------------------------ k ADDITIONAL COMMENTS -- - ---------- -- -------------- --- --------------- -------------------------------- --------- , Final fns ------------------ ------- ----Date --- + SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M i '