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� e FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT y --i (Complete in Triplicate) Permit No. --:�.f`_:�� �? - . This Permit Expires t Year From Date Issues) � Date% )`ss� ::T_� --:— 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/LOCAT19N -------, , -/1/t .l ..� .�. -�L rCENSUS TRACT Owner's Name . � ✓-h) / /!]l,S - -------- ------------ - -----.-Phone -. 7_: 5. - Address .-. ' City --- = W -------"------- _ -"--------"----------- Contractor's Name ='-T/C...... =224M C-c_------ License # Phone 6/� _=-- Installation Will serve: Residence Ej,Apartment House❑ Commercial ❑Trailer Court ;❑ Motel [] Other - ----------- 4' ----------- Number of living units:---".�------ Number of bedrooms _-2------ Grinder __ .�Q- Lot Size ------------Water Supply:Supply: Public System and name ----------------------- - - - ------------ ----------- -------------Private r] Character of soil to a depth of 3 feet: Sand'[-1 Silt❑ Clay D Peat[] Sandy Loam ❑ Clay Loam.9 Hardpan ❑ Adobe.0 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- lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) jPACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size--------------------------------------_ ------ Liquid Depth -------------------------- f Capacity -------- - --------- Type - ------------- ---- Material---------------------- No. Compartments Distance to nearest: Well ------------------------------------Foundation --- ----------------- Prop. Line .----- ---- _"------- LEACHING LINE [ ) No. of Eines --------- --------- ---- Length of each l':ne---------------------------- Total Length :----------,- 'D' Box ------------ Type Filter Material -------------- -Depth Filter Material ---- -"- i ---------------------- •-•---- --- Distance to nearest: Well .--__---- ---------- Foundation ------------------------ Property Line ------------------ SEEPAGE PIT [ ] Depth - ------------------- Diameter ----------- "- -- Number ----------- ---------_ ---- Rock Filled Yes ❑ No Water Table Depth ------------- -------Rock Size Distance to nearest: Well ----------------------------------------Foundation ---------- i --- ----- Prop. Line -- - ------•-----•---- Q, REPAIR/ADDITION(Prev, Sanitation Permit# -------------------------------------------- Date ---------------------- ) (" i ------------ _ Septic Tank (Specify Requirements) -------- -- --------------------------- -------------------------------------- ----- --- -- Disposal Field (Specify Requirements) - __/_)_-J-3e ---_ 0 ,/ 'F C- I hereby certify that 1 have prepared this application and that th - ------------------ -- --------------__ ____________ _ {Draw existing and required addition on reverse sides y y pp a work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Rome 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 becomysubject to Workman's Compensation laws of California." Signed �-�' g -------- .-------------- ----- Owner By -" if- ---- ------- --- --- ------ Title ---- .. ------- -------------------------------------------------- --------------- at er t an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- ------------------- ----- -- "A 14------ -------- ------ -------------------- DATE .----- I BUILDING PERMIT ISSUED ---------------- -- --------- ------------ ------------ ---" ----- ----- ADDITIONAL COMMENTS -- D 7E - - - 11 ------------------------------ ------------------ --------------- ---- - - Final Inspection b t,; " -------- --- --- = ------ at p y: . y ; l.i Date -144.'.._x. -.. � � SAN JOAQUIIV LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev- 5M