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FOR OFFICE USE: -y APPLICATION FOR SANITATION PERMIT f Permit ------------------ (Complete in Triplicate) No. ------ This Permit Expires 1 Year From Date Issued Date Issued _.--- `-��._ t Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: I / ri JOB ADDRI_SS/LOCATION _.2 --+ ----- / /QT -------�ll---- ENSUS TRACT -------------------------- Owner's Name �n �--------�/ 7 V14A- ,.5------------------ ------------------- �' ---------Phone - -_-�6 Address 17--(7---�-------C/57W7 e—,-e- ---_C _- _ City _ t% �P u - Contractor's Nome4 eecv.__e--_---- Qf ,.-------- - L[°---.License '�.'37-_ Phone Installation will serve: Res!dence;'Apartment House,❑ Commercial ;❑Trailer Court i❑ Motel D Other -------------------------------------------- Number of living units:----/-_._ Number of bedrooms _„2__--Garbage Grinder Lot Size _._/ Ci S__----__ WaterSupply: Public System and name -------------------------------------------------------------------------------------------------------------•-PrivateA Chpracter of_soi.l_toa_depth-of-3_fee.t: Sand.'❑ aSilt-(] .Clay -❑— Feat-❑ Sandy Loam-❑ Clay-Loam[-;,-_: -- Hardpan ❑ Adobe Fill Material ------------ If yes, type ---------------------------- (Piot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must be placed on reverse side.) ob NEW INSTALLATION: (No septic tank or seepage pit permitted if publics ewer is available within 200 feet,) PACKAGE TREATMENT f ] SEPTIC TAMC° -------------- ---- Liquid Depth _- Z-.-_-_-.--_ k Capacity -0�"�Q:--_ Type aterial-_ R1No.-Compartments T Distance to ,nearest: Well __01041 ----------------- ---------Foundation .-_ .... Prop. Line ---s------_ LEACHING LINE No. of Lines _/------------------- Length of each line_____ Q_________________ Total LengthQ-_----_--__--- 'Q' Box .._ ...__. Type Filter Material .��(._----Depth Filter Material ____f .-___.._.---__---_�__._...__. t pp � � r Distance to nearest: Well ____d------------------ Foundation ___10-______________ Property Line ---I_---------------- _, SEEPAGE PIT . Depth --/#------------ Diameter 41,Y6------ Number -----------/-------------- Rock Filled Yes� No 0 Water Table Depth -----------------------------------Rock Size ...... ------------f---_--------- / f Distance to nearest: Well ._,�.�r�___ ---------------------Foundation _______ Prop. Line ---------------------- REPAIR/ADDITION _---------_______..__REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________________________ Date ___-________________-________-____) I Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------------- - -w Disposal Field (Specify Requirements) ---- - _e------------- � -_----------------- ) ------- -----------------=---------------------------------------------------------------------------------------------------------------------------•------------------ ----=-------------_- --- - {Draw existing and required addition on reverse sidel 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 C as to beco subject to Workma"mpensation laws of California." Signed.-",7 - ------<_ �✓ --------------------Owner By ------------- ------ -- -- - --------- ----------------------------- -- ------------- --- Title ---------- ------- " (I other'than owner) i I FOR .DEP A ENT USE ONLY APPLICATION ACCEPTEQBY - --- --------------------- ---- ---------------------------- DATE -- -- --------------- BUILDINGPERMIT ISSUED - ---------------------- ------------------------------- -----------------------------------------------DATE -------------•----------------------------- I ADDITIONALCOMMENTS -------------------------- ---------------------------------------------------- ----------=--------------------------- -------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - --------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ ------------------------ ------- ----- - ---- ----- ------------------------------------------ - - -- - - - ---•------- Final Inspection by: - = Date JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M• \