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FOR OFFICE USE: APPLICATION FOR SANITATION_PELIT --------------- ----------------------------------- 7 (Complete in Triplicate) Permit No: ` /-_. --------- ---------------------------------- -- This Permit Expires 1 Year From Date Issued Date Issued /`l_'----- 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 rdinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ---- ------------ --- -- -- ---4-fv-._ l/------- Owner. _C1 SUS TRACT -------------------------- ------------ ` /� ` Owners Name W,_1• ---ic� x-------------------------------------------------------------- - - --- ------Phone - ----------- ---------------------- Address -------?�0-, � -f Cit , Contractor's Name _-�e - --- . -cam _Q--_---.License_#� 1 , --- Phone ------------------------------ .� ._ Installation will serve: Residence (Apartment House-p Commercial:❑Trailer Court C7 Motel ❑Other ----- ----------------------------- ti Number of living units:-.---.1_ Number of bedrooms r _4 Number Grinder,-- �_.- Lot Size ________________ __°--,______----..-...-. N ' I _ .-. . � y� 4 4_' Water Supply: Public System and name --- ' --Private C!r _j;�_ Character cf soil to a depth of 3 feet:",:S,and' Silt-F-] Clay 0 Peat❑ Sandy Loam ❑ Clay Loam ❑ Z! -Hardpan ❑ Adobe-E] Fill Material ----- ------ If yes,type __------------------------- r (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 260 feet) PACKAGE TREATMENT [ ] SEPTIC TANK![ ] Size------------------------------------------------ Liquid Depth --------------------------- ,4 r Capacity -----t-------- Type -------------------- Material---------------------- No. Compartments ................. Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------------_-------- LEACHING LINE {Y] No. of Lines -------- --------------- Length of each line---------------------------- Total Length ---------------------------- D' 'Box ----------'Type Filter Material --------------------Depth Filter Material -------------------------------------•------ Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ SEEPAGE PIT A[ ] Depth -------------------- Diameter ---------------- Number ----------_----_------------ Rock Filled Yes ElNo 0 i s Water Table Depth ------------------------------------------------Rock Size -------------------------------- ' ` Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ................... REPAIRJADDITION(Prev. Sanitation Permit# _------------ ------------------------------ Date -------------_-----------_----_---) SepticTank (Specify Requirements[ ------------------------ --------------------------------------------------------- ----------------------------------------------------- Disposal Field (Specify Requirements) ----- '"----------------------- - --------------- ry --------------- ------------------------------------------------------------- -------------------------- (Draw existing and required addition on 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 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 bec a subject to Workman's Compensation laws of California." Signed - - - --------------------- --- ----- Q�acrae� Y --- ------ ----------- -------------- ---- ----------------------------------- Title (If other than owned FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------------------------------------------- DATE BUILDING PERMIT ISSUED --__----_________ ---------------------------------------DATE ------------------------------ ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------- ----------------------------------------------------- ---------------------------------------------- --------------------------------------------------------------------- -------------------------------------- --- ------------- - - - - - --------------------------------- = Final Ins ection b Dat �- - = ------ --------------------------- � O- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M }