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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT # ---------- ---------------------------------------------- Permit No: '" � (Complete in Triplicate) • - -------------------- ------------------------------------ This Permit Expires 1 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 made in compliance with County 9rdinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATIO V6 Vo - ----- - ----------- - CENSUS TRACT ---------- -- ------ - -- �+O Owner's Name - --U �ne -- Ph - Addess City r / G Contractor's Name .-----_-} ' --------- ------License # Phone 0.7 InstallatFon will serve: Residence gApartment House❑ Commercial :❑Trailer Court ;❑ = Motel ❑Other _ - ` .._ ._ �7 I Number of living units--_________ Number of bedrooms ___.Garbage Grinder ------------=Lot Size -7_U ---- -�------•-------- 1 ' Water Supply: Public System and`name ---------------------------------•----------------------------- ---------------------------------------------Private Character of soil fio.a depth of 3 feet:. Sand'E] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam p ❑ �F L•.. #trial ------------ If yes,type ---------------------------- a Hard an Adobe-F1Fill'Mate (Piot plan, showing sizelof lot, location.,of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank,-,. seepage pit permitted if public sewer is available within 200 feet,) or; PACKAGE TREATMENT f[ ] SEPTIC TANKSize--------------------------------------------- -- Liquid Depth ---------------- ,----- 6*� Capacity --- ------------- Type -------------------- Material------- -- No. Compartments ----------------- + Distance to nearest: Well -------------- -`_'_. 'r____,_--_.Found Vation __ ___. Prop, Line ---------------------- 0 v .-. _ _.. ._______.__________ _ - --- Total Length ------------ LEACHING LINE [ J No. of Lines _._______-_ Length of each,'Iine 'D' Box ------------ Type Filter Material --------------!-_=_Defith Filter Material -------------------------------------------- I Distance to nearest: Well -----------i------------ Foundation•_______________________ Property Line ------------------------ SEEPAGE PIT [ ] Depth Diameter, _ _ Number __________________________ Rock Filled Yes ❑ No i❑ ----- ----------- t Water Table Depth�--'- II:_. �-------{Ro� Size -------------------------------- D ---- ----------------------p- { Distance,to nearest. VII ----------- ---------------------------Foundation ------ ------------- Pro Line ---------------- S REPAIR/ADDITION(Prev. Sanitation4Perm`it# -------------------E--=-------- Date ----------------------------------I Septic Tank (Specify Requirements) __________________ ) r _. , Disposal Field (Specify•Requiremerit0) t--- I - -. 'yam x M ________________________________________ _ _ ______-_-------._________________---------____________r_______-_--_------_._____________________._.----_______________________________ F (Draw existing and required addition on reverse side) hereby certify that I have prepared this application and that the work}will be done in accordance with San Joaquin County Ordinances, Stote 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-6f the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California."f ----------''� Signed ---- ��-�-•-=•------ f- - � --- -- ---r-- - ------------------- -- _ Owner / --- =-- �r� ---------- Title r - BY ---'------------- + ---- ----- ---- ----------------- ---------- ----- { (If other t n owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED B .--`7.___ -_ G -------- ------------------------------ DA ---. - c" -----0- --------------- ADD©fONAI COIMMENTp----=___-: - - ,--.�-_ --------DA f i 7 � O G a __________________ __________._____________.____________.____.--__.__.____________ __._.____.___-_-.--__..._._____________.____ -_-._ _.____-_ _ _____ Final Inspection by: ----- `'s' f`:_ .:_ = `='�' ----------------- -Date _L_ =_7.0_. ' SAN JOAQUIN .LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M