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- Y FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) `-..... Permit No. .7.7._:.� .. This Permit Expires 1 Year From Date Issued Date Issued .-J- Application -2 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. o� JOB ADDRESS/LOCATION _ . ............. ....... ..............CENSUS TRACT Owner's Name .......... _`j....._...... � _ g!!-f...................... ...:.............. ..................Phone --- ........ Address ----.. .... City *. • ......... ....... Contractor's Name ........ �....:!�k-RR� .. -' .,.. :__.. : .:.License # � Phone Installation will serve: Residence Apartment House❑Commercial [railer Court ❑ Motel ❑Other ------ Number of living units:.....__.. Number of bedrooms _3 Grinder. ............ Lot Size Water Supply, Public System and name .................. .. � - -� -�� - •..---:.-- - -< Private Character of soil to a depth of 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 irelation to wells, buildings, etc, must be-placed on reverse side.) {No septic tank or see NEW INSTALLATION: I i f page pit permitted .if public sewer-is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ ] ) Size..- - -- � Liquid"Depth ._�.q- Capacity �? �foo Type w _ Materiai.. � .No. Compartments .............In Distance to nearest: Well . ..._...��C '_ ............Foundation ....fQ r..........#c' I Prop. Line . .`•_!�_____... LEACHING-LINE ( No. of Lines Len th of each lin g eo . `�'?.-..._.(-f' Total Length .. c_a. •--•--.. 'D' Box T I ��• Type Filter Material ...9.��:_._..Depth Filter Material ......................•-.•-- Distance to nearest.. Well Foundation '......r...�.....: Property line �G.�f` SEEPAGE PIT [ ] Depth ..._-�.. A Rock Filled Yes ❑ No C] — .. Water Table Depth .............-----------------------------------Rock Size -------- Distance ------Distance to nearest: Well -----------•---.----_--------•---------Foundation .............. Prop. Line ............... REPAIR/ADDITION(Prev. Sanitation Permit# -__,_ _-------- ------ Date ............... ) Septic Tank (Specify Requirements) ....... .._......... ----------------- --.-•------- ------------------------------- Disposal Field (Specify Requirements) ._-.-_.-_----_ _...- ........ ........... --------- --- -- - --------------- ------------------------------------------------Y {Draw exis- ting 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: "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 :Work ' Compensation laws of California." Signed ....... ' -- Owner BYhLuu.._.. ----- ------------------•----- - --- -Title . _ . . ... ................. ...--- i other than owner} FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .................... ......................... `t-7` BUILDING PERMIT ISSUED .._....._ .................................. DATE _-./^.............�.-............... ..--- ----- ..-.---------- .. ..............DATE ............-o..--...._. ADDITIONAL COMMENTS __. ................ . - ... _.-....- --. -_---• . .....................................U. ._.---------------------..._..._ ...._._........_... ..................I----- ---.-._...•.--.--- ---...------- __._......,...............-........ _.... ..__...::..._..._.__....._......__._-__-.._..___._•......_........................... 1 ....... Final Inspection by: . ..... ........... ... �{�y,,.� .._.....---• ! UllLDate . SAN JOAQUIN LOCAL HEALTH.DIS E. H. 13 24 ).'68 Rev. 5M_ ___ - . 717? x u