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FOR OFFICE USE: APPLICATION FOR' SANITATION PERMIT ------"-may. 5 (Complete in Triplicate} Permit No,. ---- ------ ---------------------------------- --------- - Q ------------------------------------- ---.------- This Permit Expires ll Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health DistrictFfor a permit to construct and install be—wer _herein described. This application is made in compliance with ounty Ordinance No. 5A9 and existing Rules Regulations: JOB ADDRESS/LOCATION ------------ , -- - --- -CENSUS TRACT - Owner's Name -.6,-aCJ.C-------gzia - ---------------------------- - ------- - Pone f Address ` 2 Cit a Y - Contractor's Name __ --.._ (Q ------------ �•7 �� _ - V- ----- -------------------- #A��.�hon, _ �/� Installation will serve: Residence artment House❑ Commercial :❑Trailer Court ;❑ Motel ❑Other ------ Number ----Number of living units:---/�__--_ Number of be oms ._ _-- _Garbage Grirlder - e,.f-- Lot Size Z-- Writer Supply: Public System and name ______ ___ ____ __ _____ _ t ivate ❑ Character of soil to a depth of 3 feet: Sand-E] Silt❑ CI ay P any oam El Clay Loam,.[] f Hardpan El Adobe Pill Ma rial ----------- if Yes, type --------------------' (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 Ppit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK' Size ------ - - -----_-------- Liquid Depth ---------------- Capacity -- -- ---- TMateriC �i / ype Material No. Compartments _ _� ------_-- Distance to nearest: Well -----___--- ,_- * ! - - ---------------Foundation�Q--___-_-_- -- Prop. line -_-�_- ---------- LEACHING LINE [, Na, of Lines -_._____-_ _- Len th !of each line-____ `� Length f_ - �_ Total Len tl� �---------------- 'Dl -1( ' Box f1to �--- Type Filter Material -l� ll� Depth Filter Material �� Distanc nearest: Well Foundation _ -_ ' F------ -- �---- ------- ��- ------------ --------- Property Line �--- - SEEPAGE PIT [ Depth C� ---- Diameter-�//__.__ Number - `___,�- Rock Filled Yes ' No .� Water Tabfe Depth ------------(D-- --------------------------Rock Size ---- -�Z--- ----------- Distance to nearest: Well ------------- --- --------------Foundation ---_ ------- Prop. Line _ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------- - --------------- Date -----------------------•-__ ] ' _ .. . ` Septic Tank (Specify Requirements) -------------------- -- Disposal Field (Specify Requirements) ----------- --------------- --7 ---- ------------------------------------------ (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 f' 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 Workman's`Compensation laws of California." Signed ---------------------- fs Owner By ----------- ----------- ------------ j --- ---- Tit - --- -- - ./ (If other than owner) ---------------------- FOR DEPARTME T USE ONLY APPLICATION ACCEPTED BY -------- - ' ----------- ------------ ------------------ DATE . '`�9 BUILDING PERMIT ISSUED __ --____---_-_ _ DAT C --------------- - - - - --- -- ---ADDITIONAL COMMENTS ___ - _ --= '" -----------------= . . - ------------- ---------------=------ ------------ ----------------------------------------- -----=------ ----- ----- ------ -- --------- -------- ------------------------------------------------------------- - ------------- ------ ----- --•---- -- ------- -- ----------------------------------------------------------------------- ------- ---- Final Inspection by: - Date ------ .._• - r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1•'68 Rev. 5M.