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i POR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .- -1-.�� (Complete in Triplicate) Date Issued This Permit Expires i Year From Date Issued .ate- Application is hereby made to the San Joaquin Local Health'District for a permit to construct and install the'work herein l described. This application is,made,in compliance 1th o rtyti - rdinan . 549_ and existing Rules_.and�Reguld lons: t JOB-ADDRESS/LOCATION ----------2_ _ .'_-_r.__ _____�� /�)" .S__ __----__ y__-CENSUS TRACT ____ _`.--- r�c �. ^" Owner's Name / /--- -` ?._..-� ------ -- - Phone Address.. Y 4`± Z • ? - �" LS' 1U'" e` Cityf`-'--------------------------- Contractor's Name :7 �Y ------.License # -------- ----- Phone ----- - - Installation will serve: Residence Apartment Hause❑ Commercial :❑Trailer Court ;[[ � —"'•.' -� Motel ❑ Other .------------- ----------------------- Number of living units------ ______ Number of bedrooms ,6-------Garbage Grinder ____________ Lot Size -_______________________-_,!_____...____ r - ` -__-, c�� Private Water Supply: Public System and name ----- __________________________________________ Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ P t❑ Sandy Loam -❑ Clay Loam ❑ I r Hardpan ❑ Adobe'D Fill Material ------------ if yes, type ---------------------------- (Plot __ ------- ----- ---- (Plot plan, showing size of'lot,location,of system in relation to wells, buildings, etc. must be placed on reverse side.) Int NEW INSTALLATION: (No septic tank or seepaa pit permitted-if-public sewer is available within 200 feet,) ? t W 64 PACKAGE TREATMENT—[ ] SEPTICTANK;[ Si __5'?�__�_a__:__�_____l�_______ Liquid Depth __._:,5 ------- l Capacity 1��Q--------- Typeg09—_6✓7__ Material 4,. e__No. Compartmentsi __- ------- Distance to nearest: Well _CLVI ___________________Foundation __��_f .__ Prop. Lin ` e ___ LEACHING LINE [ j No. of Lines ______/_______________ Length of each line---------------------------- Total Length ------------ ----------- �fL D' BoxF Type Filter Material _ OC-/ __Depth Filter Material ____________________________________________ _ i Distance to nearest: Well -_ - ---_-- Foundation __-— _ -_ _____ Property Line . 1, - A" ;57 Depth ---- - -- --- - SEEPAGE PIT [ ] p -_ Diameter ________________ Number ---------- _-_____________ flock Filled Yes No i❑ Water Table Depth ------------------------------------------------Rock Size ------------- f Distance to nearest: Well '``-__ ____ ----------Foundation ___________°_______ Prop. Line ______________________ REPAIR/ADDITION(Preva Sanitation Permit# --------------------------- ---- ' -- Date __--_____-______________,_____-___] ' Septic Tank (Specify Requirement's)��^17r-(�-��------r----- --1'C"-- ---� --�r--�---'------------------- -� ----r---------------------------- .; Disposal Field (Specify Requirements) T ------------ ---------------------------------------- ------------ ---------------- ------ - ----------------------- ---------------------------------------------- ------- ------ - T _ _ .: _ - - ----------------------- ' (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 certifieithe following: , "1 certify that in'the performance of the-w k for which this permit is issued, 1 shall not employ any person in such manner .Y , as to become s lett to Workm s Comp satin laws of California." � . Owner P-- Signed L 1 Signed - ��---------------=-- O er dBy ----- ----- ------ ----------------------------------------------------------- ------------ ----------- Title ------------------- ---------------------------------------------------- (if ------(If other than owner) t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- <244,11- -____-. DATE -------. ~` ------ BUILDING PERMIT ISSUED ----------------------------------- -`- ----DATE ------------------------- -------------------=----------- yADDITIONAL COMMENTS -------------- - ---------------------i-------------- --- --------------'---------- -" -----`------------------- ------------------------------------------------------------------ --- -- -- ------ -- -- - - -------_---- ---------------- ---------- ---- - -- ------------------------------------------------------------------------------------------- = f �` T, ------- --------- -- ----- --------- --- Final Ins ection - p -�------ ------- --- --- ---------- ----------- --Date -- ---- SAN 3 ` . SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M G