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` FOR OFFICE USE: `'y ..... .� I APPLICATION'I:OR SANITATION PERMIT ------------------------- -------------------- =------- - _. _ ----------------------------------- - (Complete in Triplicate) Permit No. This Permit Expires T Yearn'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 appliIF cation is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION " _- -_-- G 7.h2---------- ----CENSUS TRACT --•---- --,--.--•----- J Owner's Name - i _ � / -5 =-- 61-11 - S~ ------------------------------------Phone Address ��'- 0 h r city 1 2- _W_-;,/. C p---- Contractor's Name -- __;.- --__ _�_.--e- --------------------------License #d` rJl d Phone Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ------ ---------------- ------ -"------ -� i Number of livinghunits:-/--__--. Number of bedrooms�_3--_.-_Garbage Grinder �:,--_-_ Lot Size _ `��_ `_--b-- t,f - ---- Water Supply: Public System and name --------------------- f� Private - �----------------------- Character of soil to a depth of 3 feet: Sand SiltO . t ❑ . y ❑ Peat❑ Sandy Loam ❑ Clay Loam :❑ ` Hardpan ❑ Adobe ❑ Fill Material ------------ IftYPe,es Y -�----------------------- - (Plot plan, showing `sizeOf lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) � r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { �. SEPTIC TANK [.) ~� Size-4551C5 ` i Capacity yx-_------------- Liquid Depth --- �------------ Ca �. -d Q P Y --4 ------ TYpe ---------- - Material6,,_ No. Compartments _-.._._- �f -s {� Distance to nearest: Well -__ -_--_--t_-_..........Foundation -.f__Q----____-- Pro Line _ LEACHING LINE [ ]� No+ of Lines ----_-c2-------------- Length of each T line---/-06-------------- Total M lr Length _��_-� Box ------ .--___ Type Filter Material -C� Depth--Filter Material ... ---------------------------------- Distance to nearest: Well ----c�'-�-___-----_- Foundation IIIAa_-- Property Line � .. SEEPAGE PIT [ ] Depth -----.-------------- Diameter ---------------- Number -----_---------------___,--- e )Yes ❑ No Water Table Depth Rock Filled P ------------------' 1 Rock Size --------------------- Distance to nearest: Well ------------------------------------------ d ! a = Foundation ------- ----- Prop. Line ----------------• REPAIR/ADDITION(PreV. Sanitation Permit# ..-----..__--------------_---..._ _ r i Date -------------------- Septic ------------•-----Septic Tank (Specify Requirements) -------- --------------------- i t + -----------------•-------------_------------------- -------------------------- Disposal Field (Specify Requirements) -__-_---__-_- r .e . ------------=---------------------------- ' `f f ------- ---- i (Draw existing and required addition on id reverse se) ' I 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: r "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' Compensation laws of California." a Signed ------�- - ---------- -------- Owner I BY --`---------'-- ---------- f -I other than owner) Title - -- -------------------------------------- ------------- [ FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY - ------------------------ DATBUILI �� =rQ. DING PERMIT ISSUED --- { DATE ----------- ADDITIONAL COMMENTS - - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <-------------------------------- --------- ----------------------------------------------------------------------------------------------- na Inspection b - ----- -------------- - -------- - --------------- -- P Y' -� Z -----------------------------------------------------Date --------� �a --- SAN JOAQUIN LOCAL HEALTH DISTRICT 7-'68 Rev. 5M