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FOR'OFFICE USE: - -a APPLICATION FOR SANITATION PERMIT v ---------- ----------•--------------- - t , Permit No. --------�---- — ,Comoiete in Triplicate) _ ------------------------- ------------ �t ; Date Issued _.5__=- ___ - ------------_----- --------------- This Permit Expires Y Year From Date Issued 3 Application is hereby made to the San Joaquin Local Health Distri6f.56r'a)permitto construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ILI CL J� p- CENSUS TRACT _S---- -- ---------- JOB ADDRESS/LOCATI N .-- '- � �� 1 }�-)----- ---- ------------ �. ' Owner's Name .------- � E-------- ---ED�-�--------------------------------------------- ----------=-•--- - ---- ------Phone ------------------------------------ s Q ( � Av" Add -----. CitY --------------------------- ress. 1_� Contractor's Name .------ r F - !-------------`-�--1-`--Co-- License #ailer C Phone a Installation will serve. Residence artn erifi House[. ❑ curt ❑ -- ✓ f r -Motel ❑ Other i. F Number of living units:-- ------- Number of-bedrooms _1��:Garbage Grinder _ Lot Size ----�:: _R- ------G�- - i Water Supply: Public System and name ------------- -- - ---------=------------ -- -------------------------------------------- -------Private Er- i I Character of soil to a depth of 3 feet: 'Sand'E] §ilt❑ Clay ❑ 4 Peat ❑ Sandy Loam ❑ Clay loam P�, T -. lt, r H-6rdpan Adobe ❑ Fill Material ------------ If yes,type ---------------------------- A ---- ---- ------------- a (Plot plan; showing size of,lot;' locatio'n_of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (Nro ,septic tank or seepage pit permitted if.public sewer is available within 200 feet,) LAI PACKAGE TREATMENT [ ]" SEP TIC TANK`[ j` Size---------------------------------------/tei uid Depth ---------------------.-••-- Capacity -------- ----------- Type ------- ----------- Material---------------------- ompartments ------------•----_.._. i ' Distance to nearest: LEACHING -------- ---------------------------Foundation --- -- -------- Prop. Line --------- LEACHING LINE,[ ] No. of Lines --F----------------- Le gth of each line---------------------------- tal Length ---------------------------. D' Sox i Type Filter Ma ria) Depth Filter iai .3 , Distance to nearest: Well ________ ______________ Foundation - ------------------- _ Property Line- ________________---___ � _ Number _____�____________ Rock Filled Yes No SEEPAGE PIT [ ] Depth ---___-----}; - --- Diameter -------------- r �� t - ❑4 . Water Table Depth }Distance to nearest: Well ------ --------------------Four dation -- ---------- Prop. Line ----------------_---is JREPAIR/ADDITION(Prey. Sanitation Permit# ------------- ---------------------------- Date _'_______--- --------___ ------------) �, Se tic Tank (SpecifyRequirements) , ------------1 ------------ �[ Disposal Field (Specify Requirements) --------�_D�___-.-_ ___ _-_ 2 - ' --D-- � �� p Y q - rX ! - ------------ A7 - -- --- ------ -e`r `r--- -- ------ ---- -- ------ --- ------ -T ----------- --- ----- ---------- -------- ---------- = , '`.( raw existing and required addition on reverse side) I hereby certify that I have prepaQ,4his application and that the work wilhzbe done in accordance with San Jon um� County Ordinances, State Laws, and`Rules andRegulations of the San Joaquin, Local Health District. Home owner or licen- sed agents signature certifies the.fSilowing: 1 "I certify t tin the pe0orman5e of the work-for which this permit is issued; I shall not employ any person in such manner ` as to beco subjectpto�rkanCompensation laws of California."Signed - --- --------------- Owner j ) G.. y - --------- " B ---- - - -------------------------------------------- � J -t-�-�---- title -------------------. --------------- - ----------------------- (if ------- - � (If other than owner) ` ll77 I FOR DEPARTMENT USE ONLY c "" APPLICATION ACCEPTED BY -t1J� ' - f,DATE ------- BUiLDING-PERMIT ISSUED------------------=----------#------------------------ ---------------------- ------- ---------. ADDITbNALCOMMENTS ------------- -----'^ ---------- ��:. - -------'�� J ` `�---------------------------------=--------------------------- V r , ---- ------------------------ - ------------•--------------------------------------- = ------ - ------ ----- - Finollnspectio = Date . ------- .-- (- SAN JOAQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'68 Rev. 5M