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FOR OFFICE USE: ` APPLICATION FOR SANITATION PERMIT ---------------- (Complete in Triplicate) Permit No: ,�- --_---. ---------------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This a.pplication,is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION' -•-- - : f --CENSUS TRACT Owner's Name ►l-y�s/Eic/i ��/�l'� T�'.1 ---- - ----------- -------Phone ------------------------------------ t Address �X- _�� E.h 1F � ---------------------------------------- City _,04� 4-_ Contractor's Name -- %f -- ------.License # -,9_6-4/7J_ Phone Installation will serve: Residence ❑Apartment House❑ Commercial : frailer Court MMotel ❑ Other _�S t�nn__Cf -- _C/ Number of living units------------- Number of bedrooms ------------Garbage Grinder __--- -._- Lot Size s ___ -- E?_------A_- Water Supply: Public System and name - - ---------- ----------------•------------------------------------------------------------------------------Private�° Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam El Clay ` Hardpan ❑ Adobe ❑ 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.) NEW INSTALLATION: (No septic Itank or seepage pit permitted if public sewer is available within 200 feet,] 4"PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------j--�--_3� .------------_-_-- Liquid Depth ----------- Capacity 00-0-__-__ T No. Compartments p y S- -._- Type _----------- ------ Material-r�� I�. { Distance to nearest: Well _ IQ�C?-- CaFoundation -_/0.......... Prop. Line ------------ _---__._- 11 LEACHING LINE [ ] No. of Liries - -------------- Length of each ch Eine-----1,90--- Total Length ----��©--- ----•-•-- � rr f, ©d 'D' Box f . Type Filter MaterialDepth Filter Material -----1 I Distance to nearest: Well A00-------------- Foundation __/0----.--_______ Property Line ----::47_--_--._._-- SEEPAGE PIT [ ] Depth --------- Diameter -__ _-_----_ Number ------;:1-------------- Rock Filled Yes No i❑ Water Table Depth ___, ------------------------------------ - __f __--- I p Rock Size f f• - _ Distance to nearest:-Well -------/04------------------------Foundation ___Zc9--------- Prop. REPAIR/ADDITION{Prey. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) - ---------------------------------------------------------------------------------------------------------- • ---------------------------- r DisposalField (Specify Requirements) --------------------------•------------------------------------------------------------------------------------------ --------------- ------------------------------------------------------ 1 _ 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 County Ordinances, State Laws, avid 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 becom b)ect to Workman's Compensation laws of California." Signed --- ------ Owner BY - ----------------- Title --- ---------------------------------------------------------- (If other t an owner) FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY --- - DATE -� r� BUILDING PERMIT ISSUED - ---------- - ----DATE ------------------------------ - ADDITIONALCOMMENTS ------------------- - - -------------------------------------------------------- -------------------------------------- ------------------------------------------- ------------ = '`------------------------------------------------------------------------------------------------------------------------------ --- ------------------------------- = ------------ ------------------ ------------------------------------------ -------------------------- ----------------------------------------- ------ Final inspection by: -- -Date ------- ------------------------------------ 1 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M