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* T �� . �AOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ".. ------------------------------------------ Permit No. (Complete in Triplicate) i ----------------_-------------------------------------- Date Issued _?�L_ -_7,, ----------------------------------------------------- ----- This f ermit Expires 1 Year From Date Issued :L A lication is hereby made to the San Joaquin Local Health District for pp Y q 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/LOCATION w�-S�-��_�u-nz----------- -------- --il _ _ SSSf_'_--- .__c �`E�2_rs. -:----CENSUS TRACT --------- ---------Phone ------ Address - -------- --- - -=----- --- ........ '`�------- --•-- •------------- ) Owners Name -- - r "u -------------------• city -- sh-- ----------------------------------------------------- Contractor's ----------------------------- - - -Contractor's Name -----------------------------------4--------L 1 c e n s e # / ---- Phone Installation will serve: Residence partment House❑ commercial :❑Trailer Court ',❑ { Motel ❑Other -------------------------------------------- - . Number of living units_____________ Number of �b ldrooms ________Garbage Grinder[-T�-�- _____ Lot Size __ ---_---______________ Water Supply- Public System and name ______L—L _� - - - pP Y Y --' ----------L. ��. ,_- _ -- _-. == Private ❑ , Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ t Hardpan E]❑ Adobe Fill Material ___ v 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[--,,T� ' Size___ -- ----------------- Liquid Depth --- Capacity CapacityType ! _l`�c� Materialh. No. Compartments .__��_______________ �' Distance to nearest: Well" r----_____--_--Foundation _____,lv-__--_- Prop. Line ___S___=--.:..._.___ LEACHING LINE No, of Lines ____;- ___-__-_k__- Length of each line--___ .i _ � _.__ Total Length 17°_,�............... D' Box .�/C ._ Type Filter Material __ _' -_____Depth Filter Material - fes}'`--_________________________ t Distance to nearest: Well ------------ �__ Foundation ------------ Property Line _______._.., SEEPAGE PIT Depth _ � _ `--- p ,�,J'--________ Dia -meter -- � _ Number _________ ____________ Rock Filled Yes M_—No 1❑ Water Table Depth --------1,_el �------------------------------Rock Size Distance to nearest: Wel! ----------------------------------------Foundation ---�u___- ___-. Prop. Line _________-.!' REPAIR/ADDITION(Prev. Sanitation Permits✓# -------------------------------------------- Date -----}_______------_______--__'__) Septic Tank (Specify Requirements) "-------------------------------------------------------------------------- : = ' Disposal Field (Specify Requirements) ------------------•------------------------------------------------ ----- --''------ -------------------------------------------- ------------------------------------------------------------------------------------------- F ------------------------ ----------------------------------------------------- -------------------- -------=-------------- ------------------------- ------ --------------------------------------------- (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 ft County Ordinances, State Laws, and Rules and Regulations of the'Son Joaquin Local Health District:Home owner or Ilcen- �[ 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 BY �u ------------ Title . - G7 (if other than owner) FOR DEPARTMENT USE ONLY } APPLICATION ACCEPTED BY _____ ____-_ ------- --- �—�-P,�r--- - ----------------------- -- DATE BUILDING PERMIT ISSUED ------- = _ DATE = ------------------- ADDITIONAL COMMENTS - -------------------------- - ------------------ ----------------- t--- -_ __ _:_____ ________________________ " - ' Final Inspection by: - Date `� � SA JOAQUIN LOCAL HEALTH ;DISTRICT E. H. 9 1-'68 Rev. 5M "