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FOR OFFICE USE:' APPLICATION FOR SANITATION PERMIT --------------- ----------------------------------------- Permit No: (-= �, �- (Complete in Triplicate) , Date Issued __-_--"_6`k ________-________ /�___"_t_• __0This 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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .__ YJOX- - ___ ____ T�_I�I-_-___�-_-__-____-IP -__CENSUS TRACT __�_=�_�_� //' � � Owner's Name -----` ,y `3__Z1.11 �"�---------------------- ----------- --�---- --------------Phone �,/ Lam.-�_----- ---- - - -�-; ------------------------ 14 Address -- "-c -`'� ? ----, l/ ----- -------� J------------ ty -- _ :_ Ci ••- Contractor's Name _- �_f�-__ -_ ?� -I4� _______ ___.____ License # '� Phone Installation will serve: Residence ❑Apartment Hous,❑ Commercial ❑TrageitCourt i❑ ( Motel ❑kp*f ` -Ji---------------------------- { - Number of living units------------- N4mber of bedrooms ____ ___-_6arbage Grinder ------------ Lot Size / a ------------ Water Supply: Public System and name -----------------------------------1------ ------------------------ -- ---------------------------------------Private Character of soi Ito4d dep h of 3 fe ft: Sand' Silt❑ CI y ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ .� _..__ -_ ..__.__•__-_..__ g Hardpan ❑ Adobe'❑ Fill Material _ __ If yes,type ----------------------------- (Plot plan, showi4,size df 16t, location of system in relat„i wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION;`'�i�{ o ptic tank or seepage p• -4,�rrtted if public sewer is available within 200 feet,) PACKAGE TREATMENT,- SEPTIC TANK [ ] sl� (4 Liquid Depth ------ ------------------- f ` Capacity ------------ ------- YyPe --------------------,.Material--------------------- No. Compartments -----.------------.----- "U Distance to nearest: Well --------------------------------Foundation ---------------------- Prop. Line __________.___,______ LEACHING LINE [ ] No. of Lines ------------_--_-------_ Length of each line---------------------------- Total Length ---------___................ 'D' Box ------------ Type Filter Material ____ ,.._. .__ epth Filter Material ------------________________________________ Distance to nearest: Well ------------------------i Foundat, Property Line _______________________ SEEPAGE PIT [ ) Depth --------------- --_ biameter _______________ Num er ---------------------------- 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) ------ . - --- - ----- --0-4.-ri-- -__ ----------- .___„---------------------------- Disposal Field (Specify Requirements) C. 01? ----- /yy,, TM- ��.A,------------ --_ X ----I---- --! _ == --- ---- --- --------- -------- ------ -------- ---------------- - -- ----------- - - -- - ------ ----- ------ (Draw existing and required q0,itpp,pnjev`rse side) I hereby certify that I have prepared this application and that theork will be done in 'atcorc#ante 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 cssuRd, I shall not employ 0' 4 p4rson in such manner as to become subject to Workman's Compensation laws of California.'- Signed ----------- r- --------------------------- ------- Owner By ----------------- `------ --, -- - ------'------ -------------- Titly - - -- - -------------------------------------- -------- -- - (if other than owner) _ FOR DEPARTMENT USrObLY APPLICATION ACCEPTED BY ----- DATE '� r - -�- --�z--S-----1'��---+ ----- BUILDING..PERAAIT—JSSUEO-»» IIAIF __------- ADDITIONAL COMMENTS + - ----- L 3 � ,� �._ — - --- ----- �. _. _,.r._s,.. ...,.......z........ .... .. . ..--.._-- __ - --------------------------------- ------ ---------------------- - -- --- -- - - ------------------------------------------ = -- ----- - -------------------------------- ------ -- -- - - — ---- --------- ------------------------------------ ---- , - --- Finall --- - -------- ---- - -- -- --------------------------------- to - -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M