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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - , Permit No. (Complete in Triplicate) ---- - ----- - - �--;�.� � a Date Issued This Permit Expires 1 Year From Date Issued 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: - --- - -- I /wow( -' C ACT __-� ��( ,------- JOB ADDRESS/LOCATION - = ------------------------------------------------------------------ Phonep� 'a-e-�`------- Owner's Name .= ��1/.�- ---�`y_�'tt�r1/-- ------------ ----------. City X19_ 72`—� -------------------------------------------- Address ll'O,�'"-_��---�.�L✓_.�-!�/''.F�r--- ----- ------------- - ��+�,� 0,13—- C�� Contractor's Name ---,!"--X-h-04� ----_-_.License �s�« _-2-r� Phonecv_ -- ------------------ Installation will serve: Residence [�_artment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------- ------------------------- } Number of living units:__ ------ Number of bedrooms -_ __-__Garbage Grinder -_---- Lot Size __- _ - �r<r�`5 ==------ Water Supply: Public System and name ------------------------------------- ---_______-.----Private - ------------------------------ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam 0— Hardpan ❑ Adobe ❑ Fill 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.) NEW INSTALLATION: (No septic tank or seepa a pit permitted if public sewer is available within 200 feet,) ©r ---------------�� -X f------ ---- Liquid Depth 'T_C Type-_71-/_- MaterialG!� � No. Compartments _-------------- f ; Distance to nearest: Well -— ----_---_--__-_____-__Foundation - __�.-------- Prop. Line 1 :._ . ---o-- oe LEACHING LINE [�]� No. of Lines ___ -- ---- Length of each line_ __--_----------- Total Length- S-- --------------- Q`i 'D' Box __ Type Filter Material Ave* Filter Material /-7__________________-_____._----.1--.- 01 Distance to nearest: Well _26-0------------- Foundation _ ----------- -- Property Line Q Q SEEPAGE PIT [ ) Depth ---__ ------------ Diameter --- ------------ Number ---------------------------- Rock Filled Yes ❑ No i❑ WaterTable Depth -----------------------------------------------Rock Size ------------ ------------------ Distance to nearest: Well ---------------.------------------------Foundation -_----------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) --__------------- ---`----------- ---------------- Disposal Field (Specify Requirements) --- ------ ----- - -------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- (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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed __-_ Owner ------------------------------------------------------------ G=- --- ---------------------------------- Title �'L�°',%' ,/7/ i1 ------------------------ (If other than owner) ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------------------------------------=----------------------------------. DATE - = -1-`- — BUILDINGPERMIT ISSUED - ---------------------------------------�-------------------------- --------------------------DATE ------------------ --------- - - -- - ADDITIONAL COMMENTS ___ - - -- - ---- ------------------ ---------- ----------- ------------- --------- ----------------------- --- ---------- -- -----i-- ---- ----- - - ---- -- ------------------------------------- ------------------------ --------- - - ---- ------------ -------------------------- ---------- - -------- -- - - - - -------- -t Final Inspec i ,y� J! - -- - - Date '� _ f. /.r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M