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{ FOR OFFICE USE: - { APPLICATIAN"FOR gAN1TATIQN PERMIT �71— --------------------------------- --------------------- (Comple&in Triplicate) Permit No_ ______________________ 1 ------------ -- This Permit Expires 1 Year From Date Issued Date Issued ._ -------_--- ' Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION -----------------d/__1--— _ --.------ _ _- CENSUS TRACT ---------------•-____-• A Owner's Name ----------------- ----- -------Phone _/.a3 -337j ------- ------------------------ ----- { Address9-7�------�------ City --- --- - 4 ---- ------------------------License #,/ S_// Phone _6_'74d_�------ k Contractor's Name ___________ _____ __ __ _ _� � Installation will serve: Residence Apartment House-E] Commercial ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number of living units:___. Number of bedrooms _l""lGarbage Grinder ------------ Lot Size ... __` —__________ Water Supply: Public System and name -------------------------------------------------------------------------------- --------- ------------------Private i Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat Q Sandy Loam ❑ Clay Loam f-] Hardpan ❑ Adobe [ Fill Material ------------ If yes,type ____________________________ ' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) Ll NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT- n Size__—��--: -.9, Liquid Depth _�`f____________,____. � K � -Capacity ==-Type Material��'�-_.__. No. Compartments ......'Z...........:.... } t , � � Distance to nearest: Wel( _ _____ De___________________Foundation _.__l:b___________ Prop. Line ____ ______T4_._._ Ile LEACHING LINE [ ] No. of Line`_ -----_._''�_-'__�' `Length of each aline i________________________I_ Total Length V r r D' Box ------------ Type Filter Material --------------_ :_.Depth Filter Material ______r_____________________________________ 1 -Distance to nearest:.Well __________________________Foundation ____--__-_.__�____ Propertyt'Line ,---------.______-_-----_ z n a r-�*t �•3 r • `V, AJ A VV SEEPAGE PIT [ ] Depth- _- -_'_:_____:___ -Diameter '_"'`=__ "_ Number`.-__- Rock Filled Yes ❑ No s0 -`•---i- -- r, Water Tabll Rock e ------- --------------------- l e..Depth,-- ------ ---- `--------�--------.-- x Distance to nearest: Well ----------------O*_._______.________..:_Foundation _______ ------------ Prop. Line __________.._......_.. �� t-=--- --+------- -1---�-- } ' REPAIRfADDITION{Prev. Sanitation Permit# _.______-_____ � 5l Date ___________________ f} + Septic Tank (Specify Requirements) ---------------- -------------- -=J - Disposal Field 1(Specify'Requirements) ------------------ --,---------------------- ] <9-------------- I � 4 1 i = C i r (Draw existing and required addition on reverse side) i t I hereby certify that 1 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 HealthfDistrict. Homeowner or licen- sed agents signature certifies the following: "F 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_Workman',s%Com pen sation laws of California." . Signed ---------- ------------- ` . �,( c Owner �P BY �" - " --------XX Title --------`--- 1. =. (Ifo than owner}_„- 03 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ____ _________ ______ _ _'�: ~1 DATE __ .� Q _-__�--------- - ------------------ BUILDING PERMIT ISSUED ------------------ ------- --------------DATE -------------•----------------------------- - ----------- ADDITIONAL COMMENTS ------- - - -------------------------------------------------------------------------------------- ----- --- - --------------- ------------------------------------ - -- ------------------ ------------- ------- Final Inspection by Date -- ------------- SAN JOAQUIN LOCAL EALTH DISTRICT �� E. H. 9 1-'68 Rev. 5M