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a FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / q .� --------- --------------------------------- (Complete in Triplicate) Permit No !_C -_ (J�_J ________--------------- 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 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION/�(./�--�,/ A144-1011'e , _CENSUS TRACT ......... Owner's Name ---------�f �-------------•-------------------------s- --------------------Phone ---------------------------.--------- Address _ _/_ - ±- '_ --------------------------------------------- City /_-'r/1� '--------------- y s� Contractor's Name ___'o4--a'1f?v 4 4414-0 -,moi---`-------------- --------License # --------- -------------- Phone ....................... Installation will serve: Residence [�A$�'eyjHouse❑ Commercial :❑Trailer Court ❑ Motel ❑Other --------.------------------------------------ III Number of living units:--,2-_--__ Number of bedrooms ________Garbage Grinder ------------ Lot Size/Jo,� __ -y- � - - --•--•---- Water Supply: Public System and name -----------•------------------------------------ --------------------------------------...-------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Sift❑ Clay ❑ Peat❑ Sandy Loam] Clay Loam,❑ W ; Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type _________________________ 6% (Plot plan, showing size of lot, -location of system in relation to wells, buildings, .etc. must be placed on reverse side.) I NEW INSTALLATION: (No septic tank or seepage pit .permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK:[] Size*--'"--------C- ZQ-k -__7--------- Liquid Depth A/ Capacity l�00-------- Typeell,,-_A ` Material-----6r,7 No. Compartments _ ----------------- Distance*to-'h6arest: _______________Distance`to-'nearest: Well ___gi b________________________Foundation -I t1-_____________ Prop. Linea___•-__________-_____ LEACHING LINE No. of Lines _____ Length of each line _ _ Total Length iP7 N 'D' Box Type..Filter Material •--- -_ __Depth Filter Material ___ _______. ...... Distance to nearest: Well _CO________________ Foundation ----/_Q__-___________ Property Line --___..______._.:.___ '! SEEPAGE PIT [ ] Depth:,,---------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth x------------------------------------------------Rock Size -------------------------------- fid Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line -------___......... REPAIR./ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------_-------____----_) Septic Tank (Specify Requirements) ----------------------------------------------------------------- ------•-------- -------- DisposalField (Specify Requirements) -- ------------------------------------------------------------------------------------------------------------------ --------------- --------------------- ----- ----------------------------------------------------------------------------- ----- t - - - - ------------ ------------------------------------------------------------------------ ,�_- (Draw existing and required addition on reverse side).__ �_ .- _ -,..,. .._may._,�. No I herelry 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 b come subject to Workman's ,"mpensati n laws of California." Si n ++g -- ----------------------------- ,f --- ------------------------ caner By Title - - ---- --- -- (If other t an owner) /_V FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY BUILDING PERMIT ISSUED -._-, ----- -- ---------------- ---- --- --••-- _ I-L ATE -------------•-____-- fTr ADDITIONAL COMMENTS - � -- -�-- ------- --------- ------ ---- -•-.-��Z-r--•---�-------- -- ---------+----��--- --------- ----------------------------------------------------------------------------=----- ------------------------------------------------------------------------------------------------------------ --- ` ---------------------- ------------------------------------------------ --- ------ ) - ---------------------------------------------------------------- --Date ---------------- Final Inspection by: SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H..,9 1-'68 Rev. 5M. �h.