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FOR--OFFICE- - -•USE- : -- - ------ --- ------- APPLICATION FOR 3ANITATIQN PERMIT (Complete in Triplicate) Permit No. _)Z-Z ----------------------------------------------------- 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .--__------_` ... } ---CENSUS TRACT .411-------------- Owner's Name ! _ ' - �,_ -------- Phone Address ------------- E3 �1/.Af�`-- .•( Contractor's Name ------ -- city Aw -------------- '?-. -------------------------------------------------------------------License # ---------:-------------- Phone 14 ---- Installation will serve: Residence 1]Apartment House-[] Commercial:❑Trailer Court Motel ❑Other --------------------------- Number of living units:... ------ Number of bedrooms ---/------Garbage Grinder ------------ Lot Size __4&_---_ ____ _______ Water Supply: Public System and name _ __________ ------ - - ---------- --------- Private.a9 - Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam] Clay Loam[] 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.) NEW INSTALLATION: fNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) O PACKAGE TREATMENT [ ] SEPTIC TANK _____-.--- Liquid Depth ______________ ___ � ] Size-----------------••---------- -- ______ --- � Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------------- -•--- Distance to nearest: Well -------------------------- --___-_-._.__ ___ -_-__..Foundation ---------------------- Prop. Line -------___.._.--------- LEACHING LINE j ] No. of Lines .------_-_------------- Length of each line---------------------.------ Total Length 'D' Sox ------------ Type Filter Material --------------------Depth Filter Material -_--_--_-_--_- 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/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----•--------------•--------____-) Septic Tank (Specify Requirements) ---_-_-- Disposal Field (Specify Requirements) -,AVIV, �- �-__,� t� � �►�� ------- -------------------------------------------- -------------------------------------------------------------------------------------------------------- (Draw existing and re_ ired 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 become subject to Workman's Compensation laws of California." Signed ...0 ----- BY --- - - -- -- --- -------- - --T19it0V itle- ---------------------------------- -------------------------------------------------------------- ot er fihan owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ------ BUILDING PERMIT ISSUED ------------------------- - -- ------------------------ ADDITIONAL COMMENTS -- ------------- --------- - DATE ------------------- ---------- -------------------------- ------------------ ----- --------------------------------------------------------- ------------------------------------------------------- ._ Final------------------------------sionb - ------------------------------------------------------------------- ---------- ------ Final Ins action b --_- -- - - ----:----- !' Y " Date 11 - ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. SM