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FOR OFFICE USE: _ APPLICATION FOR SANITATION PERMIT /(� --- - -------=------------------------- Permit No. (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 t described. This application is made in compliance with County,Ordinance No. 549 and existing Rules and Regulations: 41 -PCENSUS TRACT r ( JOB ADDRESS/LOCATION/ --------�� _��` Owner's Name -Was-----45Y, �-0-W----------------------6-±-------------- -------------------Phon�r�_ 73.� Address -----------41 -r PhoneIF�_� � City �. � ` C _.: _ r -`-�..��J`�[� Contractor's Name _�-��1��-------------------- -------------------- --------------License i�G.$ Installation will serve: t.,Residence LTJ Oartment House❑ Commercial :❑Trailer Court ❑ Motel ❑Other ------ -------------------------------------- e' Number --------- ---------------------- - Number of livingunits`_._ Number'of bedrooms . I ` ,�-- -- �____--Garbage Grinder��--- Lot Size; _-f___ ----_-�`�----------------- �- Water Supply: Public System and name ----------- e- - -----------Private - Character of soil to-a depth-of 3,feet:v Sand [Silt❑ Claya.❑ Peat❑ ,-. Sandy Loam ❑_ Clay Loam.;❑ _ { Hardpan ❑ Adobe ❑ Fill Material___-_ If yes,type ___________________________ F I v1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) "4 ! g °C NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,, PACKAGE TREATMENT SEPTIC TANK' Size_-7__ ---------------fLiquid Depth'- ------------ A --------- lCapacity/ ---2 - Mferiao= om artments {. (� Distance to nearest: Well _ ----_.__,____-____________Foundation �_�_____-___ Prop_ Line ______________ LEACHING LINE [ No. of Lines �----_____------ Length of each line__--5------- ------ Total Length - ..-_.___-____ `t ;D' Box __ __ Type Filter Materiaf4ke--___,Depth Filter MateriaPfrl-l_ hne _ ____ ______ i Distance to nearest: Well _____________ Foundation � ____._______ _ __ petty SEEPAGE PIT [ j Depth -------------------- Diameter ---------------- Number ----------------------------- Rock filled Yes '❑ 'No 0 Water Table Depth --- - -- ---------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. bine _----------_--_- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------------..---1 Septic Tank (Specify.Requirements) -------------- ----------------------------------------------'---------------- ----- -----------------• ---------------•--------•-- Disposal Field (Specify Requirements) --------------- ; -------------------------------- ------------------------- -------------- ---------------------_------- ----------------------------------_-----• ------ - - • ----- ' (Draw existing and required addition on reverse side) i 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: "I certify chat in the performance of the work for which this permit is,issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------ ------------- Owner BY J �� . `=--------------------------------- Title -.�, F/� � JIC,JAov _ (If other than owner) ' FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY '--�i-R--��-`------------- ----------- ---- ----------------- DATE .-- BUILDING PER ISSUED .--- `-- ------------------------------ ------------ DATE ------- -------------------- ADDITIONAL COMMENT --- ------ ------- - ------------ 7 ` . . ------. ... ------ -------------------- --------------------------------------------------------------------- ------- I ---------------- ---- -- -- - -- - - -------- -- ----- ------ ------------ ------------------- Final ---------------�r - - Final Inspection ------------------.Date - ---------� `- i SAN J AQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M,