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FOR OFFICE USE: APPLICATION FOR SANITATION PIERMIT + � '_��__ Permit No. (Complete in Triplicate} ----------------- ---------------' _ ------------------------------------- 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: JOBADDRESS/LOCATION ----- �------,--/YOdf1----- f? � ------- o --------------CENSUS TRACT -------4_ ------ 4 Owner's Name. t� =- G!_ �1 /----------------=------------------------ ------------Phone ._. t / ' � � t - 6 e Cit �''�1 _ -� 'C Address �/ � Y -- ------I----------------------------- Phone I Contractor's Name {/ --lY<�.�Ljl��! -- -F�- ----49-License # ---------------- - Installation will serve: / Residence Apartment House❑ Commercial :❑Trailer Court !❑ Motel ❑ Other ------------------------------------- Number of living units:_______ Number of bedrooms _______Garbage Grinder _____._.___ Lot Size __ ! _______________________ �,. t I � .•ter - Water Supply: Public System and name ---..-------------------------------------------------------------------------------Private ❑ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK:[ f `. - Size-`---_- -_ _ `' ` `� r � ... r [ ] - - - - - - �'` , .Liquid Depth Capacity --- ------ Type --- ---------------- Material---------------------- No. Compartments ................. i I r Distance to nearest: Well ___________________________________Foundation ---------------------- Prop. Line ...................... O f LEACHING LINE [ ] No. of Lines __ __.__•__________ ____ Length of each line _ -__._ _______._____ Total Length_ 'D' Box -_I-___.____ Type Filter Material --------------------Depth Filter Material --------------------._______________..____ Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _-______-.___ _.___ i. SEEPAGE PIT [ ] Depth ____!______________ Diameter Number _________-______.___.______ Rock Filled Yes ❑ No i❑ ------------- -- t Q Water Table Depth ------------------------------------------------Rock Size --------------------------- '�` .•+ Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... J Ir REPAIR/ADDITION(Prev. Sanitation�'Permit# -------- ----------------------------------- Date ----------------------------------) f 1 , 1 Septic Tank (Specify Requirements) ---------------- "'- -------------- Disposal ---------Dis osal Field (Specify Requirements) r 15; ' `i--- 7 wi,11------ ----- ----------------------------------------------- - -----------------------------------------------------------------------------------------------------,------ -------------------------------- (Draw existing and required addition on reverse side) ` : I hereby certify that 1 have prepared this application and that the work will be-done-inaccordancii-with San Joaquin County Ordinances, State Laws, and Rules and Regufwtions 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 lams of California." g - Si ned -------- ----- ".`.� ---------- r .4 By Title f other than owner r I. DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -.-- - - - -------- ------------------------------------------------------------ DATE �� - � ------------------ BUILDING PERMIT ISSUED ------ -------- -----------------------------------------------------------------DATE --------- i ADDITIONAL COMMENTS ------- --- - ------ ---------------- - = t .i _ ______________________________ j �t /ver-- - --?,t% ....--�-�G-j-- ! -- -- - --- -- -------------------------- -------------- ------- ------------------------------------- -------- ------- Final.Insection by: -- --- ' ---------------- --- -------- --- -------------------Date / -- --------------- N AQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'66 Rev. 5M