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r � .l I w �✓* FOR OFFICE USE: ' APPLICATION FOit,SANITATION PERMIT Permit No.. ----------- (Complete in Triplicate) Date Issued--A)3'7?-3-7y -_----_-------------------------------------- ----- This Permit Expires 1 Year From 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 County Ordinance No. 549 and existing Rules and Regulations: JOE ADDRESS/LO ATION ��_ 1 s_ cJ_---------/ -------��-Cl----------CENSUS TRACT ---------------------- 1 � �-� i ------`'/-l-tw --------------------------------- = ------------------.Phone ------------------------------------ I Owner's Name ��} �, Address _ __ _ --- ---- ?�3- a� ------------------ City / ! v "7 '1 ---------------------- Contractor's Name __ - �--- - "�---------------------------License # - 1'�J- Phone59 Installation will serve: Residence Apartment House-[3 Commercial :❑Trailer Court 10 Motel ❑Other - ------------------------------------------ Number of living units:_._------ Number of bedrooms ---f______Garbage Grinder ------------ Lot Size __/ e' -----,r.-------.----.--- Water Supply: Public Syste'm and name ----------------------•---------------------------------------------------------------------------------------Private ❑ n ' Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay E] Peat E] Sandy Loam Clay Loam Q Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ___------------------------ • I� (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) Ni} NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,J PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size---------- ----------------- -------------------- Liquid Depth ..----------------------_ I � capacity -------------------- Type -------------------- teria!- -- ------------- No. Compartments ----------- .......... Distance to nearest: Well -----------------" -- -------------F unclation ---------------------- Prop. Line ---------------------- 0 LEACHING LINE [ } No. of Lines ________________________ Length o each lin ___._______.___--------____ Total Length ----------- -------_------- - 'D' Box ------------ Type Filter Materia ______________ _____Depth Filter Material _________-____________-..._._______._.._._ Distance to nearest: Well ____________ ________ Fo ndation _._________.___________ Property Line ____-._.__________--_-_- SEEPAGE PIT [ ] Depth ____________________ Diameter _______--_-____ umber _.____.-.-_______._______--. Rock Filled Yes ❑ No i❑ Water Table: Depth ------------------------------------------------Rock Size Distance to nearest: Well ____.__________________________________Foundation -------------------- Prop. Line ----____-- ........... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date s -----------.----------------------- Septic _____=____.---_----Se tic Tank (Specify Req'uirements) - 1 :-------------- ------------------------ ------------------ -------------------•---------•------------------ ----------------- ------- _____ -k------ Disposal Field (Specify'!'Requirements) -__.__l_41s _____-_��e ..........0_9W ----------- ------- -`V 4?----------e> eF ------- 1 (Draw existing and required addition on reverse side) 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 ILaws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: I "I.certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed - ---------II- ---------- Owner ------------------ BY -------------- ---` Title ---------- ------- -------- - ---------------------------------------- (if other thai owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 'BY - ------ ------- --------------------- -------------------------------- DATE BUILDING PERMIT ISSUED ---------------------- --- - -------DATE - ---------------------------------------- ADDITIONALCOMMENTS�-----------------------------------------------------------------------------------------------------------------------------------=----------•---------------- -------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------- --------------------------- -- ---- ----------------------------------------------------------------------- ------------- --------------------------------------------------- . - --------------------------------- -- -- -- ------------------ ------------------ ------ - - - Final Inspection by: ----------------------------------------------------- Date ------------- SAN J AQUIN LOCAL HEALTH DISTRICT ii II E. H.'9 1-'66 Rev. 5M �h - "