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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - -------------------------- ------------------------------ Permit No. . - (Complete in Triplicate) --- ------1- ----------- ------------------------------ Date Issued -�..--c-"-7-3-. r __--------- ------------------------ ------------- This Permit Expires 1 Year From Date Issued r. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicatioriE�is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: / i � %y-------------------- -------------- ----CENSUS TRACT --------------- --.------- JOB ADDRESS/LOCATION --- ---------------------- Owner's Name ----1 _ ----toyv,I/-'A'/ l� ----------------------------------------- ----- --- --Phone "r ------- i is �L' -------------•-•------ 3 Address -----�,�---Y+3-- II' DI_1,11.Siozv----------------------------------- City /�/11�! / Contractor's Name ---___.License # ^�' �a----- PhoneZ73�4 S �1 Y Installation will serve: Residence KApartment House-E] Commercial❑Trailer Court �❑ Motel ❑Other -------------- ----------------------------- t Lot Size q Number ---------------- -- -- Number of living units:--- -- Number of bedrooms �-----__Garbage Grinder ------------ Lot Size � �/"C-------••------ Y ,��. ------ -----------------------Private ❑ Water Supply: Public S stem and name --- - -----------------•------------ ----------------------•---------------- Character of soil to a dept I!of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam f- Clay Loam 0 i �I Hardpan E-] Adobe'❑ Fill Material _.---------- If yes, type ------ --------------------- t I t �I. r (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,) i PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------_----.----------•------- Liquid Depth .--_----------------•.•---- W l Type -------------------- Material:--------------------- o. Compartments r Distance to nearest: Well --/ne --------------------- --Foundation ---------------------- Prop. Line ----------- ----------- 11 .LINE [ ] No. of Lines ----------- -----_----- h of each ine------------- -_--_.------ Total Length ------.--_-.-----__-_----•-- D' Box --------- --- Type Filter al -_--_-- -----------Dept Filter Material ----------------------------- IM! Distance to nearest: Well ---- -------- Foundatio ---------------_ -_ Property Line. -------------•----•----- L --------- Rock Filled Yes No i❑ O- � SEEPAGE PIT [ j D��pth ___-•-------------- Diamete ---- -_ -- Number ------------------- ❑Water Table Depth -------------- ---------------•---- --Rock SizeI`Distance to nearest: Wetl ------ ---------------- Foundation -----_-------------- Prop. Line _..----------------.-- IREPAIR/ADDITION[Prev. Snitation Permit# ------------- -------------- ------ Date --_--.--------------__----_-_-----} Septic Tank (Specify Requirements) -------- --------- ------------------------=--------------------- ._----------------------_-•- Disposal Field (Specify,: Requirements) /------------------------- i -----2 Lvlye-------- nl -fix _/ ------------ 1-514 -------- Z -------- --------------------------- ---------- (Draw existing and required addition on reverse side) l 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Statell.Lows, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: 4 "I certify that in the pert rmance of the work for which this permit is issued, I shall not employ any person in such manner f as to becoq t to Eorkman's Compensation laws of California." Signed _ - a -!�=---------------------- --------------------------------------- Owner BY ----------- ---------;--------- -- - ---------------------------------- Title ------- - ------- ----------------------------------------------------- E er than owfier) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED11BY --------------- --- DATE ---- -- ` ------- ------- -------------- ---- ----- - --------------------------------------------------- BUILDING PERMIT ISSUED ---- -------------------------- - - - --DATE - -------•----------- --------------- ADDITIONALCOMMENTS:---- -------------------------------•--------------•----------- -•------------------------------------------------------- ------------------------------------ ------------------------------ -----------i[----------------------- ------------------------------------------------------------ -------------------------------------------------------------------------- -- --------------------------------------- ----------------------------------------------------------------------------------- - 11- ------ - ---------------------------------------- - -- -- - - ----- -------------------------------------------------- ---- ----------- - -- - II--------Final Inspection by, ---------- � - -�-.•---------- -- --------�------ - ---------------•••••----.Date --- -- --------- ------------ SAN ----------SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M