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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. __ ___ __ l - {- _ 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 anal;Regulations: v � , JOB ADDRESS/LOCATION '��-_-�*-_ -�/Ll -_gip _.___----_----i�T - CENSUS TRACT --.-._.6_-._--_-_--- Owner's Name ---if/ ;et / 1J4 %-------------------------------------------------- -----------Phone2� � Jd'`� . Address -------14Fc'�'l-------- � [/`-%<f+� o ------------------- City : ✓% -� --------------- ----------------- Contractor's Name _ f / --_____.License #�� ------- Phonec�°'�_-��-�'�' "y Installation will serve: Residence t1kpartment House❑ Commercial []Trailer Court ;❑ Motel F-1Other -------------------------------------------- ...yy Number of living units:---,/__--_ Number of bedrooms � _Garbage Grinder f� __ Lot Size c2_�---o��-------- Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private '.. Character of soil to a depth of 3 feet: Sand f[ —Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material _&J&___ If yes,type -------.___.-_--_-___-___ (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 seep a pit permitted if public sewer is available within 200 feet,) q� PACKAGE TREATMENT [ I SEPTIC TANK,[ Size---9r-_-Y ____________ Liquid Depth -.'/�_. ------ ---__ Capacity _P< TypwW�_n7_ Materia600� / _No. Compartments __.................. /�U Distance to rarest: Well Q_-_-______-_.___.___.____Foundation / - ---- --- ---- Prop. Line /- - ----------- LEACHING LINE [� No. of Lines _ __1_/_ ________-__-_ Length of each line__�Q�-_-._______ Total Length .fQQ------------------ 'e� 'D' Box ____--.-__.Type Filter Material. �f�?_C/�-__-_Depth Filter Material -_�.�--_______________________________ Distance o nearest: Well _4?c-------------- Foundation l7/ --f---------- Property Line l am_/------ .__ SEEPAGE PIT [ ) Depth _____- ----------- Diameter ---------------- Number ---------------------------- Rock Filled Yea '❑ N i❑ Water Table h ------------------------------------------------Rock Size -------------------------------- Distance to ne�ai .,- Well ----------------------------------------Foundation -------------------- Pro . i e ............ REPAIR/ADDITION(Prev. Sanitation mi -------------------------------------------- � Date -__---__-_--_-___--------_--_-__ *� _-___ ) __Se tic Tank (Specify Requirements _ -------- Disposal Field (Specify Requirem nts) ----C_ XX ------- /_- T� _ -4�_ _---- ------ - ----- - --..___ ---------------------- ------------------------------------------- ------- (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 accordanc6"with San Joaquin,, County Ordinances, State Laws, and Rules and Regulations-of the San Joaquin Local Health District. Home owner or liven-'i sed agents signature certifies the following: "I certify that in the performance of the work for which this perntit is issued, I shall not employ any person in such manner as to'become subject to Workman's Compensation laws of Califofnia." Signed ------ Owner _. By ----'- ' _ • - ------- - - ---------- --- --- Title -(�/•�-�f�?9 (If other than owner)' f` FOR DEPARTMENT USE O APPLICATION ACCEPTED BY --'--------------------------------------- ---------------------------- DATE ---- -4L7- BUILDING PERMIT ISSUED ------------------------------ --------------------------------- ----------------------DATE ADDITIONAL COMMENTS �----------- ----------------------- --------- ---------------- ------------------ ----------------------- --------------- ------------------ --------------------------- ---------------- -- --- - --- -- -- -- --- - - --------------- - ----- -- - --- ----- --- ---------------- -- ---- -------- .. --- -- -- - - ----- -- - - -- - ---- ---- -- --------- Final Inspec � - --- -- -------- - - --- Date -- ' f" y -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M