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LOFFICE USE: APPLICATION FOR AANITATION PERMIT` - tPermit------ -------- ---- ---- ----- (Complete in Triplicate) ---------------------------- -._... Date Issued-------------------- ------ . ---- 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. 49 and existing Rules and Regulations- CENSUS TRACT -------------------------- JOB ----------- ------------ # JOB ADDRESS/LOCATIO 412-4 - - --- Owner's Name :.----- -- - ----- - --------------- / - r-_ � -✓�,� Phone yCa� � /-cQ�- �1�_a4�_�L city - - --- -- - - -------------------------- Address _ --- ---------------- �'i j.-� vC-------.License #/S3 Phone - � Contractor's Name _. -- Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other ------------------ ------------------------- Number of living units:---- Number of bedrooms _.l---------Garbage Grinder ---.-------- Lot Size --------------------------------------------- Private ❑ Water Supply: Public System andEl name . . Character of soil to a depth of 3 feet: Sand F] Silt❑ Clay E] Peat El Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe CK_Fill Material ------------ If yes, type --------------------------- (P p g ip lot Ian 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,) \� PACKAGE TREATMENT f ] SEPTIC TANK. ] Size---------------------------------------- - Liquid Depth ------------- o, _---- No. Compartments ------ Capacity - ------------------ Type -------------------- Material----------------- p -- ----------•-- k :_Foundation ---------------------- Prop. Line ---------- ------ Distance to nearest: Well - Length of each line---------- ----------- Total Length N; LEACHING LINE [ } No. of Lines ------------- g E 'D' Box ----- Type Filter Material --------------- Distance --- ------ --------Depth Filter Material -.----------------------------------•------- i Foundation ___---------- Property Line ----------------•------- Distance to nearest: Well _-.-___-_______._ ------- -f-------- - ---- Diameter ----- Number ---------------------------- Rock Filled Yes '❑ No � SEEPAGE PIT ( } Depth -------- Water Table Depth Rock Size ------------ -- 'I Foundation -------------------- Prop. Line ---------------•------ REPAIR ADDITION(Prev. Sanitation nearest: Well -------------------------------------- - Distance / on Permit# -------- ------------ ------- Date ------- ------------------------- 1 -- ----------------- ---------------------------- Septic Tank (Specify Requirements] .. _- - s --�--'.°-- - -----`�� ---- Di osal Field (Specify Requirements) __. ---&14 ------------------------ - ----- --- - ----------- -- ------------------------------------------ - p (Draw existing and required addition an 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 o. 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 rnanner .+ti; as to eco ject to Workman's Compensation laws of California." Signed�L s- [--t --- - ----- k � --------- Title -------------------------------- ----- ---- -- -- ------ -- (If other than owner) i F R DEPARTMENT USE ONLY l ' r - -- - -------- /--------------------------------------------- DATE - f ( -; APPLICATION ACCEPTED BY .... -- _-- - ,r DATE ---------------------- ------- BUILDING PERMIT ISSUED ---- ADITIONAL CO TS --- �, ------- ---- -- = R------- -------------- -------------------------- ---------------------- ---------- ------=----------- -- = _ _:_ ------------- ----------------- - -- - --------- ------ ------ --------- ------------------ - ----- - -------- ------------------- - ------------ ----------------- ---- --------------- Date -_ = = r Final Inspection by: -__- -- - _ - - - N JOAQUIN LOCAL HEALTH DISTRICT C E. H. 9 1-'68 Rev. SM