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1'"" � f FOR OFFfCE USE: ------ --- - -- - ------ --- - APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: -- - --7. -------------------------------------------------------- This Permit Expires.I Year From bate Issued Date Issued Application is hereby made to the San Joaquin focal 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/LOC TON ------- ---- - - _ CENSUS TRACT ------------------------ Owner's Name - _. (� - I -----Phone_f � Address `-= ` 1.�" ---- - ------------------------------------ _ City --- --- Contractor's Name _______ ___ [� �� 7*aP�'�Q� Pei- ------ ---- - - ------------ ----� -c1_�'Y�c-'---- ---License # _!� ------ Phone - ---------- ._---- --- -- Installation will serve: Residence KApartment House❑ Commercial❑Trailer Court ❑ Motel ❑ Other 9 Number of living.units:_._-___�_��.Number of bedrooms __ _ _� ., . _Garbage Grinder Lot Size i Water Supply: Public System dnid name ___________________________ ! I -. " ------------------------------------------ -------r--------Private ❑ Character of soil to a depth_of 3-feet: Sand'❑ Silt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ - g Hardpan ❑ Adobe Fill Materia) -----.------ If yes,type -------------------------- (Plot plan,i showing size hof lot, location of system in relation to wells, 'buildings, etc. must be placed on reverse' side.) NEW INSTALLATION: No septic tank or seepage pit permitted if,public sewer is available within 200 feet,) yPACKAGE+TREATMENT [ ].' SEPTIC TANK'[ )Y ?Size_41 ---------------------------------' r ty ------------ Liquid Depth ----------- r,^Ca'acct j t �.. -.�_ - } y --------- --- Type ---------- ----- Material---------------------- No. Compartments--------------- ...... (!� Distance to nearest: Well -------------------------------------Foundation ---------------- ----- Prop. Linef __..•----.•--:--_--••- 1 LEACHING LINE (�] s No. of Lines ------------------------ Length of each line-------------------------.-- Total Length. ------...-_•---------------- 'D' -----------'D' Box --;-------- Type Filter Material ---- -- ------------ - ` i t A x 'Depth Filter Material ----------=--•-------- i � Distance,to.-nearest: Well.__--.______________ Foundation Property Line'f ------------------------ SEEPAGE PITS [-] Depth `` Diameter --------- ----�----� ---------------- Number__ --- ------ -------------- Rock Filled . Yes ❑ No Water Table Depth --- _ ---- -------Rock Size t 9 #:yam Distance to nearest-. Well .�__).",4; - -------- ---------------Foundation --------------- ---- Prop. Line -------------------- P _. REPAIR/ADDITION,.{Prey.-San i'tation Permit'i Y. _ __: X96-------- pate_____ Tank Septic (Specify Requirements) ----------------- ----------- -- - ------ ------------------------------------------------------------ Disposal Field (Specify Requirements) --- -- 4 �,�.� -- ----------- -------- ----------- 106-- -- ------ ------- ----- --At- ci�k--- -------------------------- ----------------- -------- - - - --------- --------------- '(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 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 -- ------------ - ---=----- - -------------------------------- i By - ----------- ---- -- - - ------- __1------ Title ' If other th owner] ` -------- - --------------------------------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- DATE ---- = ��-2 BUILDING PERMIT ISSUED ------------- - ----- ------- } --------------------------------- ------------- --- --------------DATE ----- ------------ ADDITIONAL COMMENTS ----------------! ---------------•- ------- ---- ------------------------- err-----�=�:_ ---- - - •_.- -----__ ---- -------- �' � a`� - - ----------------------------------- ------------------------------------------------- :v`"'r_ Final Inspection by: __._ i �-- e =---------- Date ------ ---------------------------------SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.