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FOR OFFICE USE: 5 A�f -_ -- �.. PLICATION FOR SANITATION PERMIT ---- ` ;- --- �Z. ---- ' Permit No: _-Z.� (Complete in Triplicate) -- �'_�___ �j ____________ » ThIs Permit Expires 1 Year From Date Issued . Date Issued .7' Application is hereby made to the San Joaquin 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/LO''••C`ATION .__�'____I___�_`C_.____e_______An4grAla-,-____ -__CENSUS TRACT __________________________ Owner's Namett _tt�.1�-'�_k,�_._------ujv. -----------------------------------r---------------_------------------- -Phone ------------------------------------ Address -� Wit'[-Z-----�-------��^_ .1�---------------------------_ City ---5�-�--------------------------` 1- Contractor's Name --------------52_-[----------------------------------------------------------License # --------`-l--------- Phone 4�o_ ..b9 Installation will serve: Residence Apartment House[] Commercial ❑Trailer Court ❑ / Motel ❑Other _ r -------------•---------------------------- �..�.1 Number of living units:_______ Number of bedrooms -�-_Garbage Grinder __ ________ Lot Size _ x:_�_S _______________ Water Supply: Public System and name _ G_____- _____�-___-_<f_1N_-�--------------------------------Private ❑ Character of soil to a depth of 3 feet: SaIYN'❑ Silt❑ Clay ❑ Peat 0 Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe' ill Material ____________ If yes,type____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) (A NEW INSTALLATION: (No septic tank or seeps pit permitted if public sewer is avail le within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK;[7 _Size_{__._�_�__ _._ _ __�_________ Liquid Depth __________________________ Capacity � _____ Typ `-�'S Material__��i1^C.._ No. Compartments __ " istance to nearest: Well ---------�---- ______Foundation _____ _ _________ Prop. Line __� _j......... LEACHING LINE No. of Lines --------1--------------- Length of each, line-__ 1 ,____-____ Total Length, ----- tt �{ 'D' Box ._____.___:_ Type Filter Materia"�1�-_____ ilter Material ------Lq_______ __ - --------- Distance toneeaargst: Well ____________________r__ Foundation ----- d ------ Property Line ____ ___.____.._____ SEEPAGE PIT Depth ________ ________ Diameter _ ______ Number ________________________ Rock Filled Yes '�No 0 Water Table Depth ------------------------------------------------Rock Size -------------------- - Distance to nearest: Well ________________________________________Foundation ---- ----- Prop. Line •------ --__.________ REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) Septic Tank (Specify Requirements) ---rnQl-�------- w✓L---- t --- - --- --`---_----_---------------------------------------- Disposal Field (Specify Require encs) ____ ________ ____ ___ 1 - --___ ------------------ --------------- ---- - -- ------------------------------------------------------------------- ----------- ------------------------------ - ----------------------------------------------------------------------------------------•-------------- (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 certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to becom u lett to Workman's Co ation la of California." -- Signed - - ------------ _------------_ Owner By ----------------------- ----------------------------- ---------- ----- --------------- Title ----- ------ ------------------------------------------------------ (If other than owner) FOR UPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- - - --- ---------------------- ---- ----------------------------- DATE -- 5 - ------------ BUILDING PERMIT ISSUED --------- ------- - -----------------DATE ----------------------------- ----------- ADDITIONAL COMMENTS ---------------------------------------------- ------------------------------------ --------------------------- --`-'" -- ---- C. ` (c_ --------------------------------------- ------------------ ------------------------------------------------------- ------ - �� - -- ------------------------------------ ------------- - - - ---------------------------------- - - - -------- -------- ------------ --------------------------- -- - ------------ ---------- ------------------------------------------ SAN - - - - - - - - - - - -------------r Final Inspection by: --------- -r - ----- - ------------------Date -- - - - - SAN JOAQUI LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M