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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------- Permit No. --r-��-=/ r Q (Complete in Triplicate) -------------------- ;4 .- =fThis Permit Expires I Year 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 application is m6de in compliance with County Ordincince No. 549 and existing Rules and Regulations: = --------CENSUS TRACT -------------------------- JOB ADDRESSfLOC TION .-*`:__`_'�F�_! -,------------- - � � Owner's Name-- - ----------- -------- Add ---- = Phone i Address -- 4� ----------------------- n, -------------------- ti gin, s6i Contractor's Name ----------.License #9-----?' --��---- Phone ----------------- --------- Installation will serve: Residence XApartment House❑ Commercial:❑Trailer Court # Motel ❑Other -------------------------------- I--------- r = Y' Number of living units------ Number of bedrooms -_9------Garbo Garbage, --------- Lot Size ___-_Q- , --------- - y t �,, � Private ❑ Water pplyf: Public System and name ! - ---------------------------- Su L •_ Character of to a depth of 3 feet: Sand'[-] Silt[3 Clay,❑, Peat E] Sandy Loam El Clay Loam .. a �-• Hardpan E] AdobeFill Material ----- ------ If yes,type ------------------------ (Plot plan, showing size of lot, location of system insrrelation 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 [ ]_ SEPTIC TANK'[ I ._. » Size --------------k----- --•--_- ---7-Liquid Depth..__---------------------- Ca acit -------- .No. Compartments -------------•-------- P Y -----------------•-- TYPe ----------------- -- Material--------t_._.- I { Distance to nearest: Well ------------------------------------FounAotion ---------------------- Prop. Line _:------------- ------ (� 4 LEACHING LINE [ ] No. of Lines ------------------------- Length of each line-------- -------------•----- Total Length -----.......---------------- Material �f _De Depth Filter Material k 'D' Box .'---------- Type Filter Material ------------------- P - -°' t Pro er Line jDistance to nearest: Well ------------------------ Foundation _Y-------------------- P tY ---- 1tiSEEPAGE PIT [ ] Depth ----------- Diameter --------------- Number --:------------------------- Rock Filled Yes ❑ Na �] Rock Size -------------------------------- op. --------------------------•--- i Water Table Depth ------------------------------------------------ - - t ` Distance•to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----------•---------- REPAIR/ADDITION(Prev. Sanitation Permit# ------:---------------------- Date l Septic Tank (Specify Requirements) ---------------------------------- " - ��--------� --------------- Disposal Field (Specify Requirements) __-- Q ____ - ------- ----------------------------------------- 7 t r ' ------------------------ -- ---------------------------- Y 4 l- (Draw existing and required addition on reverse.sidel_. ,.,,,,.. _ -! p r I hereby certify that I have prepared this application and that the work wi0be 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 f the work for which this permit is issued, 1 shall not employ any person in such manner as to be a su j ct to W km s Compensat* n laws of California." { 't�C�°`----------- Owner t Signed - - Title --------- ----=------------------ t i t BY (If otherthan owner} ' - FOR .DEPARTMENT USE ONLY r � C, I ` --��-------------------------------------------- -----__..---. DATE -- ��-7_ r'- 1--------- ----- APPLICATION ACCEPTED BY ----. BUILDING PERMIT ISSUED ---------------------- _-DATE ------------- ---- l . -� , -- ADDITIONAL COMMENTS ------------------------ \--- ------------------------------------ -- -------- - ---------------------------- --------- _ f - - - t _...------ ---------------------------------------------------------------- ( .• ----- ---------- ate ---- ------ Date --------------- Final Inspection bY� -------- ----- -�--- �=--------- --- -- -- ----------- -------------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M N$N