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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � _" Permit No. 7(2._1.174- --------------------------------- ------------------ (Complete in Triplicate) _ -------=-- -------------------------------------------- Date Issued 1-11 " Af�—This''Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local I-Iedlth,District for a permit to construct and install the work herein described. This application is made,in compliance with C66niyPrdinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _ !_ ._9a , f � � �""�'__CENSUS TRACT ------------------------•- ---- t'' Phone �10-6�-- - Owner's Na ------ _ ----- --- - -= -------------- ------ Address ---- u"+'�---- - City �L � ! ------ Phone .'Yr=�.-�_^-��-&� Contractor's Name -------------------- -�4�[/,�_�-------.License #�'.�-. - � - - -- -t-- , Installation will serve: Residencl(Apa tment House'❑ Commercial ❑Trailer Court ❑ Motel ❑Other ----------- Number of living units:... __------ Number of bedrooms ...Garbage Grinder ---------- Lot Size .--- Water Supply. Public System and name ---...__-.-- -- :__._..-- Y Private -•r--- ------- ---Pea# ❑� Sand---Loam ❑ Clay-Loam.[] Character of soil to a depth of 3 feet: Sand'❑ Silt❑ lay ❑ Hardpan ` Adobe�X 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.) r NEW INSTALLATION: (No sep�#tank,or seepage#pifilpermitted if public sewer,is available within 200 feet, } i . Liquid Depth -------------------------- PACKAGE TREATMENT r[_]_SEPTIC TANK•[-]. Size----------------------------------- q p -. Material----- --------- ----- No. Compartments ; Capacity - - Type -- - ----------- --- Distance to nearest:4Well ------------------r---------------Foundations;-------------------- Prop. Line ---- ---------- Distance of Lines ---------- ----------- Length of each line----------------------- Total Length LEACHING LINE C ]� � 'D' Box -------- Type Filter Material ---------------- ----Depth Filter Material -------------------------------------------- Distance to nearest-•Well--- ---Y--- - Foundation ---- --_)Property Line ------------------------ 1 ---- ---- --------- Diameter ---------------- Number -------.----- t" t 'Rock Filled Yes ❑ No '❑ SEEPAGE PITS [ ] Dept } Wat r Table Depth ---------------- -- ---------------- i-i Rock Size _ = I t Distace to nearest: W.el.l'..*--- --_- ------------ `.....Foundafiion 1111t -+------ Prop. Line ---- - ,... ( .. Date ----------------------------------) I REPAIR/ADDITION(Prev. Sanitation Permit s# -------------------------------------------- I -------------------------------- - Septic Tank (Specify Requirements) -------------------------------------------------- ---------------------------------------------------------------------------------------- Septic ------------- ------------ # -- - ---------------r----------- " -�� Disposal Field (Specify Requirements) - -.__ _. �� a t � (J f ' ----------------- ---- $ - - ----------------------------- ------------------ - - --- - u � R Draw ext tin 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 YSan 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." - ----------------------------- Owner Signed -- - ----- --- - ------------- -------- -I---- Z- -A- ---- - > - - ------------- Title (If other t owner) ? FOR DEP TMENT USE-O.NLY APPLICATION ACCEPTED BY ---- -- ------ --- - - ' - DATE` --- --- ---- BUILDING PERMIT ISSUED --------------------- - - - --------------------------------------------------- "f ')--DATE ------------------------------ ------- --- ------ ADDITIONAL COMMENTS ..---_---- ----- ----------------- ---------------------------------- ------------------------- --------- ---------------------------------------------------------------------------- - --------- ---- --- ----- ----- --- ---------- -------- Finans l ipection by: -- - - -- --- - ------ -- - - ----- -•----- ----------------------- - -----Date --------- ------- - ------- SAN - ---SAN JOAQUIN LOCAL HEALTH DISTRICT f E. H. 9 1-'68 Rev. 5M