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FOR OFFICE USE: ��"* APPLICATION FOR SANITATION PERMIT �'/' ----------------------=------------------------------ Permit No:�7' ;Complete in Triplicate) -- ----------------- ------=--�---------- ------------------------------------ - 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 ap fication is made in compliance with County Ordinance No. 549 and existin Rules and Regulations: S�j r !� x JOB ADDRESS./fLOC(A7 0NW_1yiPA_/------- ------- -��1-�------ ----C�- ".---- �'- CENSUS RT ACT ------ ---------- �/Cry ? -------------------------------:--------------- ----- - - ��--.�._.. Owner's. N�yame /�� 1_________Phone.7071_ ® 6 Address -1 -.47 - �Yh Ci �71�-T"s-C_ " --- - - - - -- --- Contractor's Name ____ �-" _ _I_ r�R _ License 4_4f_ Phone -- -- � Installation will serve: Residence Apartment House❑ Commercial :❑Trailer ; Motel ❑ Other --------------------------------- A r W0k3t e.0 Number of living units:---I------- Number of bedrooms _____Garbage Grin der IV--�-- Lot Size _ C _-{----------- Water Supply: Public System and name ------------------------------------------ -------------------------------------------` -- Private Character of soil to a depth of 3 feet: Sand'❑ Silt-0 Clay E] Peat Sand Loam„ Cla Loam. 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 tank or. eepa pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK`[ Sze_ j( hy f ------ Liquid Depth .. e th7_- ..... -Type ______________Capacity _ L - f / Distance to nea. rest: Well _______ _________________Foundation --- -------------- Prop. Line __fi--------- LEACHING ______LEACHENG LINT: kA_11 No. of Lines ____.�C,-______________ Length of each line.____�t __,_-_-___ Total Length - tgo_.___.__._ v 'D' Box ---I_---_---_ Type Filter Material _f?�Q_a/c—_Depth f=ilter Material ___ 7_---------______________________._ r Distance to nearest: Well ------16 /_____ Foundation ____f 4�-__I------- Property Line- ___ �_____._.:.__ SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled -Yes '❑ No i❑ Water Table Depth -------------------------------------------------Rock Size ---------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop_ Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------_----------------------- Date ________________________________) SepticTank (Specify Requirements) --------------------- ------ ------------------------------------------------------------------------------, ----------------- - ------- Disposal Field (Specify Requirements) -----------------------`' ---------------------------------- ------------------------------------- ------------------------------------------------------------------------------------------------------------------------ - -----------=------------------------=------------ ----------- ------------------------------------------------------ -- -------------------- ---------------------------- (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, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: - t "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to Workman's Compensation laws of'California." Signed_-- --- ------- - ---- ---i------ --- f ------------------- - Owner By ------ --� = CSU Title ------------------------------------------------------------------- (If other han owner) FOR DEPARTMENT USE ONLY '-N APPLICATION ACCEPTED BY 1= 1= ` --------------'---------------------------------------------------------------------- DATE ------- ` ' -- BUILDING PERMIT ISSUED ---------- ----------DATE ------------------------------------------- ADDITIONAL COMMENT _-- -- ___l T�--__ !QC?" �------p--- --------------------------- ------ - ------------------- --- --- ---- -- - ------------------------------ -- - -- �r ---------------------------------- ------ ---- - --- ---------- =/Q---� �--------------------------------- ------- --------------------------------------------------------- -- -- -=----- Final Insp Date ____-- _-_-- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.