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,FORAOFFICE USE: s APPLICATION FOR SANITATION PERMIT - "; = -------------------4 -------� � 3-a----- s [Complete in Triplicate) Permit No. _eV_^_ 11 __ Vo--------------- ---------------- - ------------ -- ____-_________ This Permit Expires i 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 Countyl Ordinance No. 549 and existing ules and Regulations: JOB ADDRESS/LCCAl- ----- -- ' -- -- -- - -- ---- - --------------CENSUS TRACT -------------- ------ Owner's - -Owner's Name --- --- ------- --------------------- P n -------------•---- Address ----._ _ ._ �� city - -------- i ----------------------•--------- Contractor's Name ---- _ '-------- _..-sCd-- ----- r 4— LicensePhone InstaF llation will serve:---Residence *Apartment House-E]House-E] Commercial :❑Trailer Court . .. . ._ _ Motel ❑Other Number of living units:----- Number of b Brooms ---- Grinder VOr-_ Lot Size ____________________ Water Supply: Public System and name -__ _ - -------�- ------------------------- ----------------------------------------------------------Private ❑ . Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam Hardpan E] 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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK! p Size_ ��++ ! r r 3a - --�- P----------- Liquid Depth ------------------ Capacity/.a-47q-6ALType Material_ _ _._._ _ No. Compartments ---P_______.. � r t' Distance to nearest: Well ____%IS . _ ____________________Foundation ---/"_C------------ Prop. Line ____�?--- ...__._____ LEACHING LINE No. of Lines /--_________ Length of each line._______ .-_ -------yp - - -� ��---------- Total Length -------.�C�` 4 'D' Box ----0--- Type Filter Material -1�"�s'_._ ______Depth Filter Material _------.__._ r --------•- --------- I Distance to nearest: Well _._S9_-"r_______- Foundation --/ -f---------- Property Line ----- .--............ SEEPAGE PIT [ ) Depth -------------------- Diameter --------------:. Number ---------------------------- -Rock-Filled Yes ❑ No i❑ --`DiWater Table Depth ------------------------------------------------Rock Size ---- Distance stance to nearest: Well ----------------------------------------Foundation -- -------------- Prop. Line ---------------•---•- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ .Date ._____________ Septic Tank (Specify, Requirements) ________ ----- ___- �__r_- ��-- - --------- Disposal Field (Specify Requirements _,.._____ --------- L� ��'f-- --------- t -------------------k---_, ---- - � ' - (Draw existing and'-re; red addition onreverse side) ----- -»+ -a + I hereby certify that I have prepared this application and.that the-work~will be done in accordance with Son' 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 f ---------- Owner------- - --- -- , $Y i -~- � Title (If other than owner) ` FOR DEPARTMENT USE ONLY --- APPLICATION ACCEPTED 8Y Q_._?--- - .----------------- DATE ___..___)--C/ _= BUILDING PERMIT ISSUED DATE _.. ADDITIONAL C¢�1�4ENT -------------- - __- - ----------- ---- _ - ----------- --------------------------------------- --- ------------------------------------------------------- -- ----------------------------------� ?1t,' Final Inspection by: ----- - ------ -- Date --- Q-� ._-� _ -- 1 --- - - ------• ---------- ------ r� JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M