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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------ �_ (Complete in Triplicate) Permit No0- -----------------------------------------.--------------- This Permit Expires 1 Year From Date Issued Date Issued �t, Application is hereby made to the San Joaquin Local HealObistrict 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: �t JOB ADDRESS/LOCATIO - ---- -- ((i/L� ---- � CENSUS TRACT -------------------------• ---------------------- _ b Owner's Name ------ ---- �L Phone ��.' a-- -- Address ---------------------- --- ---- - _� -------- - ------ City --- ----------------------------------------- Contractor's Name -------------- - O�-v� License #�QS/I Phone -- � �t(pd-7 Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ;❑ i Motel ❑Other ---------------------------------- Number of living units_-__[_----- Number of bedrooms ___'__Garbage Grinder ------------ Lot Size ________________________________________ Water Supply: Public System and name _________________ ____--_------_------________________Private ❑ -------------------------------------- ------------------------------------------------------------------------ soil to a depth of 3 feet: Sand Silt CIa i£ , Peat Sand Loam Clay Loam. P �❑ ❑ Y ❑ ❑ Y ❑ Y ❑ Hardpan ❑ Adobe Fill Material ------ If yes,type ____________________________ p (Plot plan, showing' size of lot, location of system in'relcit'ion to wells,'buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pi` permitted if public sewer is available within 200 feet',) PACKAGE TREATMENT [ ] SEPTIC TANK [Size____ k��' ___ �. ,�,. ----- --------------------- Liquid Depth --- -- ----------...... capacity tt YP9, ``'` t - - -?y - T _ Material__-_-_�____. _ ._ No. Compartments _____..____.__._.__._ Distance_.to..nearest:_FW611 ----�------------ FY-•------_Foundation,,:--C-d----------- Prop. Line i LEACHING LINE [ ]` No. of Lines -------------',__________.Length of-each line____.___`--------- - --- Total Length ............................ 'D' Box ------------ Type Fil!W Material __�------------Depth Filter,Materiai ------------------------------------ ------- Distance to nearest: Well ------ __________a___ Foundation'`_" ' ----------- Property Line _...._------1.------- SEEPAGE PIT [ ] Depth' ;: - Diameter , _____________ Number _.__________________-Rock:Filled;\,Yes 0 No 0 � •Revs ':.. ,�T d'`�.�..-�.-- ., ! i��.�.�?�� Water Table Depth --------- -`_ '. �F� Rock Size _`"' .� � ---�'--- - Distance to nearest: Well -----------------------1--"'""'° `Found&tion ------------- _`Prop. I Line ---------------------- REPAIR/ADDITION {Prey. Sanitation Permit# -------------- - ------- Dat --:--- ------ o �. —-� Septic Tank {Specify Requirements) - - - ------ - ---- ---------- ------- Disposal ----„Disposal Field (Specify Requirements) i- '°------------------------------------------•--------- ---- ---------•--------------- t -------------------------- - - - - ------------------- - - - - -- ---- (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 i 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 l "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." 3 i - Signed -----------------------�- --- ---- = = Owner By ----- -` - -- Title ----------QS4 ------ - (If'other an owner) FOR TMEN7 115E ONLY k APPLICATION ACCEPT_ED_.BY--------- ----_ ------ ----- -------- ----------------------------- DATE -------- BUILDING PERMIT ISSUED ----- --- ----- -------- ----------------------------------------- ----- --------DATE ---------------- -------------------------- ADDITIONAL COMMENTS -------- ----- - ----- = --------------------------------- ---- _ - - ---, ------------ -- ------•- ----- ------------------------------------------------------------------ ------------------------------------------- E co' - Final Inspection b - �- PY- - -- ------- - ------�--- -..� ------ -----------------------.Date SAN ,OAQUIN LOQ L HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M