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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. --------------------- ---------------------------- (Complete in Triplicate) -------- ------ e�FF �o •> Date Issued �-�---____ . `_ F This Permit Expires 1 Year From 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 i"s made incompliance with County,Ordinance No. 549 and existing Rules and Regulations: C / _CENSUS TRACT _ JOB ADDRESSAOCATION . ___l- s Owner's Name --------- ----- L?-{'�tf - - hone ::--------- Address -------- �� City '' l Contractor's Name -- ---- -----------.License # ------- ----------------- Phone -------------------- Installation will serve: Residence] Apartment House-[71 Commercial ;[7]Trailer Court i❑ { Motel ❑Other -------------------------------------------- Number --------------------- --------------------Number of living units:___- _ Number of bedrooms ---Garbage inder :,,�_ -_ L Size _-AkOA_Jko----------------- Water Supply: Public System and name ------------------ ----------------------------- ---- ---------- - '-------------------- Private E]Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ eat❑ Sandy Loom ❑ Clay Loam;❑ / .- Hardpan ❑ Adobe Fill Material ------------ If yes, type ------------------;---------- (Plot :` -_(Plot plan, showing size of lot, location of system in relations to wells, buildings; etc. must be placed on reverse side.) 1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) f PACKAGE TREATMENT [ ] SEPTIC TANK'{ ] _ size-'--'---, ----- ------------------------------ Liquid Depth -------------------------- J� Capacity --------------- -- Type - ------------------ Material`--------'---'------ No. Compartments ------ ----------=---- �. . , . Distance to nearest: Well --- -------------Foundation ----------------------.Prop. Line _.------------ 1 LEACHING LINE [ ] No. of .Lines --------------------- Length of each line---------------------------- Total Length ,___---____,_______________ 4 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------_-----------_----•- Distance to nearest: Well ________________________ Foundation ------------ ----------- Property Line ---------- SEEPAGE PIT [ ] Depth ------ ------------ Diameter. ----------------- Number ----__-__-______ ---------- Rock Filled Yes ❑ No'.i❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance --- ------Distance to n_earest:.Wel,( ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------`- Date ---------------------------------- Septic --------------------------------Septic Tank (Specify Requirements) -- ------------------------ --- -----------------------= ={:-------------------- ------------------------------ --------------------------- Disposal Field (Specify Requirements) -GY---6'-------------------- -----------------t---- - - --------- ------------- --------------------------- --------------- -'l ` -------------------------------------------------------------------- ,(Df aw 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 become subject to Workman's Compensation laws of California." Signed ------------------------ - ------------ -- ------- -- - Owner ------------------------- By ------------- r---------- - - - - - ----------------------- -Title -------------- r----_------------------- -------------- (I o er th wner) - 4 FOR EPART ENT LUSE ONLY R APPLICATION ACCEPTED BY ---------- 1191--- - ` -- DATE -----�_�1-� --------------------- BUILDING PERMIT ISSUED ------ ----------------------- -- -----------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS - ---- ------------ -- ------------- -- -- ----------------- - -------------------------------------------------------------- ------ ------------- --- ----------------------------------------- ---- -- ------------------------ - ------------------ --- j r Final Inspection by: -------- --- --- t : ----------'o,------------------- --------------------------------- Date / �f -- ---- -------- S JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M,