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p _ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT qPermitNo. Complete in Triplicate) This Permit Expires 1 Year from Date Issued Date Issued _ - --- . Appiication is hereby made to the San oaquin Local Health Distriet,for a permit to construct and install the Work hereindescribed. This application is made in compliance with County Ordinance No. 549 and existing Rules aril°Regulations: JOB ADDRESS/LOCATION ._ _ ---" f ------ --- -_ t CENSUS_TRACT ---- Owner's Name Ph one Addressi CQ j f. City Contractor's Name License Phone Installation will serve: Residence WApartment House Commercial :Trailer Court i Motel Other ---- --------------------------------- Number of living units:__-- Number of bedropmst__ arba a Grinder -__ Lot Size ____'_ h----------------- ii Water Supply: Public System and name Private Character of soil to a depth of 3 feet: Sand' Silt Clay Peat Sandy Loam - Clay 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 frfS?// Z_ SSize------------------------------------------------ Liquid Depth - ------------------------ Capacity ------------------ Type ----- -------------- Material-----. ------------- No. Compartments ------•--------------- 6 Distance. io nearest: Well ____________________________________Foundatio----------------------- Total Length ---70--______-_________ t- D' Box __ ------ Type Filter Material .I7 ___Depth filter Material ----- _-----____________ ______ Distance to nearest: Well ----- -----------Foundation__ C>- ____*---- Property Line _____'_______________ SEEPAGE PIT [ 'Depth _ _ _,__ ___ Diameter ___ __________rNumber Rock Filled Yes No z Water Table Depth Rock Size ----- Distance to nearest: Well ----- Foundation __Aa--____-- Prop. Line ------------____-. REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date --------------------------.------ ) R. Septic Tank (Specify Requirements) ------------------------- ------ ----------------------------;.------- -------- ---------------------------,-.------------ ------------ Disposal Field {Specify Requirements) _: L< xz 11 F----____________________----;-________________----_-_____________:___---._:-,_,-___________________-------_-______________' F______-__--------------- Draw existing-and--required dddifion 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° ! tare,Laws,'and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- 1 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." f:Signed ------------Owner By -------- t -- ---------- Tit! -: If other than owner) `i t I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE --------0 ---Z- BUILDING PERMIT ISSUED . DATE ------- ---------------- ---------- ADDITIONALCOMMENTS ------- Z -4--------------------------------`--------------------- ------------------- --------------------------=----------------I--------- P ----- ------------------------------------ --------------------------- ------------------- ---------------------------------------------- -------------- ------ L_4Final,Inspection by: __"____ Date -- -- --------- SAN'JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M