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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No, L� ! ` �f --------------------------------------------- ---- - t (Complete in Triplicate) ---------- --------------------------------------------- Date Issued --------------- This Permit Expires l Year From Date Issued Application is hereby made to the San Joaqu4 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/LOC N _I�_x __ /A`-- ------------------------------------- CENSUS TRACT -------------- ----------- Owner's Name -- - ----- T------ --------------------------- -----------------Phone ------ Address -----101,2-10 ---- --- --------------1- City ---- --- ;----------------------------- -------------_------ --- ------------.License # 1-��-�_��Phone ----------- Contractor's Name __ "----------- Installation will serve: Residence Kpartment House�❑ Commercial ❑Trailer Court ❑ # Motel ❑ Other -------------------------------------------- Number of living units:.--/ Number of bedrooms ---I--------Garbage Grinder ------------ Lot Size ____-_.___--------_______- Water Supply: Public System and name --------------------------------------------- ------------------------ ---------------- ------ Private ®- Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 'Olay Loam:❑ Hardpan ❑ Adobe ❑ Fill Material ---- ------ If yes, type ------- ------------- i (Plot plan,_showing size-.of..lot,«locution-•of system in relation to wells, buildings, etc. must be placed on reverse side.) .-42 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ? aciiY ` I - ------ Liquid Depth ------------------- = {" PACKAGE TREATMENT [ ] SEPTIC TANK Size------------------------------------------ Compartments -____,-_----- --------- Type -------------------- Material-------------.-------- No. Distance to nearest: Well ------------------------------------Foundation ---------------------I Prop. Line ----_---------------- �. LEACHING LINE [ ] No. of Lines _______________ ________Length of each line---------------------------- Total Length _-_______-----.____________ D' Box ------ Type Filter Material ___________________Depth Filter Material -_- -._-_________--__________-...__.__._._ Distance to nearest:,.Well ________________________ Foundation ------------------------ Property Line. -------------- --------- SEEPAGE PIT [ ] Depth -------------------- _______________ Number ---------------------------- Rock Filled Yes ❑ No_Q Water Table Depth i "^ Rock Size -----------------4------ 4 Distance to nearest: Well ----------------------------------------Foundation _----------------- #Prop'. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# _------------------------------------------ Date ______----__________-_-----------_) , Septic Tank (Specify Requirements) ------ Disposal Field (Specify Requir encs) - }��06 ---------------------- ` .+ c ---------------- -- - - ------ ` ------------------------------------------------------------------ ----------- (Draw existing an required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordancewith 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: ' "1 certify that in the performance of the work for whichthis permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---------------- ----- ---By ---- ------- " Owner ------------------- --------- ----- ----------- -------------- Title - - - ------------------ ------ (If other an owner) - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -------------------------------------------------- ------------ DATE �'----6 9-------------- BUILDINGPERMIT ISSUED --------------- ------------------------------------------------------------------------------------------DATE ---------------------------------------------- ADDITIONAL --------------------------=--------------ADDITIONAL COMMENTS ---------------------------------------------------------------------•---------------------------------------------------------------------------------------- ----------------------------- -=- --------------------------------------------------------------------------------------------------------------------------------------------------------- -- ------------- --s;- ----------- = ------------------------------------------------------------------------------- e-- Final Inspection by: . ----- -----------Dat .- s�-"- -- --- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.