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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT f (Complete in Triplicate) Permit No: _--.-.-- ----------. ------------------------J-------------------- -----._---_---_---.--__.--_--- This Permit Expires 1 Year From Date Issued Date Issued --.�-Z:_ Application is hereby made to the San Joaquin Local Health Distri fora permit to construct and install the work herein described. This application is made i� eancj f 549 andxisting Rules and Regulations: JOB ADDRESS/LOCATI. N - __ / _.-_ _ ----------- -------- f- dYz 'V 6 ---- ---- .. .__ ENSUS TRACT ---`S- - - -------------- Owner's Nam ---- --- -------------------- Pone Address Contractor's Name / ' r • = Cit �`. Y -_ ----------------- - ----------------------------- -- ---------------License #I,�rs�._3 F.7 Phone '------------------ Installation will serve: Residence ❑Apartment House-[] Commercial:❑Trailer Court i❑ ' Motel ❑ Other fNumber of living units------------- Number of bedrooms ------------Garbage Grinder. ------------ Lot Size ----.-----_--_--_------.- Water Supply: Public System and name --------------------------------- ---- _ ___- Private Character of soil to a depth of 3 feet: Sand'E] Silt 0 Clay E] Peat[:] Sandy Loam Clay Loam:❑ I 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) CIO PACKAGE TREATMENT f ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth _-------.-------..-------- Capacity -------------------- Type -----------------=--- Material---------------------- No. Compartments Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --.__-----__-----_--- NE { ] . ------------------------ geach line Total Length - ------ .--.....--------- RING LI_ Noof LinesLength of h li —, D', Box ------------ Type Filter Material --------------------Depth Filter Material _----._.-_- •`ti ------------------------- - Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line --------------.---..._- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------.--------------------- Rock Filled Yes ❑ No 0 Water Table Depth ----------------------------- ------------------Rock Size ------------------:------------- Distance to nearest: Well ------------------------------------•---Foundation ------------------ Prop. Line -----------------_--- REPAIR/ADI?ITION(Prev. Sanitation Permit# -------------------------------------------�_ Date ----------••------ _--------) a \. Septic Tank (Specify Requirements) --------------------------------- i ------ ----- _- - �1) Disposal Field (Specify Requirements) --- _ ---_ _. ---- ---- ------- �� � OZJ E ---- -- --- ----- ------------------------ --- ---- - - + (Draw e i ting and requi ed a Ilion on reverse side) " I hereby certify that I have prepared this plication and that the work will be done in accordance with Son 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 Wo an's Compensation laws of California." Signed ----------- --- f Owner BY ------- - --------------- ----------- - - Title ; 01 / - lLc-�E1-ti (If other than owner( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY ---------------- ------------------- ----------- . DATE A2 BUILDING PERMIT ISSUED .`L DATE ------ ADDITIONAL COMMENTS ------------ ------ - ----------------------------------------------------------------------------- ---------------- ---------------------------------------------------- __ - ------------------------------------------------------.------------_-_-_--------__-----_•--------__--.---------.-.-=--'--.-------------- -`-..--_-_-.------ - ----------_-_--- -- -------..- --------------------------- --------------------------- --'--- ------------------- -----------------------------------------------------Final ---------- --- -- -- ---- Fina! Inspection by: Date ! SAN JOAQUIN LOCAL HEALTH DISTRICT y E. H. 9 1-'68 Rev. 5M - . f