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F(TO OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------- Permit No: (Complete in Triplicate) - --------------------------------------------------------- This Permit Expires i Year FromDate Issued Date Issued __.67/f::_0 Application is hereby made to the San Joaquin Local Health District 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: JOB ADDRESS/LO TION 3-CYC"?,------(?P/ ---r CENSUS TRACT. : -- ------ Phone � -----------------------Owner's Name---- -- Address `111 ------ ��'r 1 •— -------------------- City Contractor's Name .r ,._ i=- -------------- -------------=-------License 1' Plioher 44 Installation will serve: Residence KJ'Apartment House❑ Commercial:❑Trailer Court 7 Other -- Number bedrooms cf-' Garbage-Grinder--�____-__"Lot Siie� ---- x y 57 Number of living units:-_- _-- � °'� -------------------.----------•--- r ,-. ------- Private Water Supply: Public System and name __________"_-_-.__ "-- -----•-~------------ - Character of soil to a depth of 3 feet: Sand'❑ Sil.t.El Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe'[ Fill Material .__-----___ If yes, type __°_- _________________ t . ' (Plot plan, showing size of lot, location of system`,in relation ta,wells, buildings, etc. must be placed on reverse side.) seepage p t•permitted if public sewer is available within 200°feet,) NEW INSTALLATION: (No septic tank or 1. - 4-1 Size Liquid. Depth -Y-- PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] f _ eZ-a T e� C�c`�o "Mater al ?c_...-s-'�--'�No. Compartments ' Capacity -/---- ---- YP ,�. _._. " Distance to nearest: Well ---'- --------- ------ -Foundation s_.. ------------- Prop. Line _.-- LEACHING LINE [ ] No. of Lines __ 41 - r _ Total Len�t�h C? "' Len th of each line__- �_.__-_--<,_ ► t t 'D' Box .__/------ Type Filter Material 1 ____Depth Filter. Material _�1'___________________________,____•-:-- . 9, f r Distance to nearest: Well __ _�.--"---.1 otindafiion __ b-- ----- --- Property Line ______________ F 2 teJ SEEPAGE PIT [ ] Deptl ---- Diameter ---------------- Number _-- 4`------------------- Rock Filled-I Yes ❑ No i❑ _ � F Water Table Depth '----------- - Rock Size Distance to nearest Well ---------------------------------------Foundation --------------------•.Prop. Line :---------------•-_--- REPAIR/ADDITION(Preva Sanitation Permit# _----------------------- --------------- -- Date ----------------------------------) i Septic Tank (Specify Requireents)m = r Disposal r field (Specify Requirements) ----- -- , • w' .�', ------------------- ------------------------- =------------------•------ ------ ___ ______________ __ ________________________"___.____�--___._ _-_______ r lw'r r �- {Draw existing and required addition on reverse side) r 1 .hereby certify that I have prepared this application and that"the work -will be done in accordance with San Joaquin �Y- 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 "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 rt Title ------------------------ ------------------- ------------------------- {If other than owner) FOR DEPARTMENT USE ONLY ------- ---------- f APPLICATION ACCEPTED BY _ DATE `'-1 .0-------- BUILDING'PERMIT ISSUED ------ '--------=--------------------------------------------------- --------- DATE ------------------------------------------- ADDITIONAL ------------•---------------------------- ADDITIONALCOMMENTS -- --------------------------------------------------------------- ---------------------•------------------ ---------------------------------------------------------- ------------------------------------------- - ----------------------------- ---------------------------------------------------------------=---- ---------------------------- ------------------------------------------------------------------------------------- ----------=-_-- r = �1' - Final Inspection b Date I p y= = -- SAN JOAQUIN LOCAL. HEALTH DISTRICT l ' E. H. 9 1-'6B Rev. SM