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FOR OFFICE lSE: °' `, -APPLICATION FOR SANITATION PERMIT --------�-G-��----- ...... Permit.."•�� (Complete in Triplicate) '_______ This Permit Expires 1 Year From Date Issued Date Issue .—_f6_-_- 0 Application is hereby made to the San Joaquin Local Health District for a permit to construct and ' stallll�thdf Aiork herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: :. n JOB ADDRESS/LOCATION --- 1------�.-- `-C,-P p�\�- -__"---------------- ------------------CENSUS TRACT V--- -------------- Ow.ner's Name ��? --------------------------------------------------------- --------------------------------1Phone ��3D�1�----------- Address - �� -------------i Qtr? C � City K`y------_-------------- -------------------------------------- Contractor's ------- ---------------------------------------------------License # ------------ .- - ------- Phone ------------------- f Installation will serve: Ij Residence {'Apartment House,F] Commercial ❑Trailer Court ;❑ MpMotel ❑ Other -------------------------------------------- Number of living units:1---------- Number of bedrooms _______Garbage Grinder 19-0--- Lot Size --.___\p-.��______________ i Water Supply: Public System and name ------------------------------------------------------------------------------ -------------------------------Private, I H Character of soil to a depth of 3 feet: Sand'0 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam '[] �I Hardpan ❑ Adobe Fill Material -I` O--- 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 f ] Size------------------------------_--------------- Liquid Depth -------------------------- CapacitY� ' Ty NG+ctt2 _ Material__�Ct��i_e_ No. Compartments _____________ Distance to nearest: Well ------------------FoLmdation ---\Q-------------- Prop. Line ___�_ [ l 1 LEACHING LINE No. of Lines .__ ._- __._______ Length of each line_.._ � ______-_.___ Total Length ----�1_®______________ (! 4 D' Box - ✓.___ Type Filter Materialsgt %lyl---Depth Filter Material _-_._._!-�9_____________________________ / / Distance to nearest: Well -1,50"t-------- Foundation --an_..___________ Property Line _�5_________________ �i SEEPAGE PIT Depth ._____-_.___._____- Diameter ---------------- Number _____-__________-__________ Rock Filled Yes E] No 0: a . Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- it REPAI /AUD[TIbN(Prev. Sanitation Permit Y# _:__-._,:_-________________________________ Date _______________________._________) Septic Tank (Specify Requirements) ---- ----------------- =,,-------------------------------------------------------------------------------- ---------------------------- f Disposal Field (Specify. Requirements) ----------------------------- --------------------------------------------------------------------------------------- --------------- ----------I--------------------------- ------------------------- ------------------------------------------ ----------------------- --------------------------- ----------------------------------------------------------------------------------------------------------- - (Draw existing and required addition on reverse side) I hereby certify that 1 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 as to beco te s _ tt Work an's Compensation laws of California." Signed ✓• ' -----------'------�_ -------------- ----> - - ------------------------------ - Owner it ,. BY --- ------- Title - ---- ----------- --------------------------- (If other than"owner) N FOR .DEPA1tTMENT�USE ONLY APPLICATION ACCEPTED '8Y -Aw A ''1-- - - .. BUILDING PERMIT ISSUED --.- ----------------------- ------------------- ---- ---- ------------------------ DATE ------------ ------------------------- ADDITIONAL COMMENTS------------- r - -- -- --------- -- -.r - ---- --- E- ------------------------------------------------------------------ ---- ------ ------- - - -------- - ------------ -- -------- ------ - LU -� - ----- --- -��✓ Final Inspection by: ---------- � --------------------------------------------------------- ate ---- - --- h SAJOAQUIN LOCAL HEALTH DISTRICT lieI�P {i E. H. 9 1•'68 Rev. 5MI! A