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FOR OFFICE USE: ,APPLICATION FOR SANITATION PERMIT 3 �- Permit No. ........ ------------- ------------------------------ , . . .� {Complete in Triplicate) - Date Issued � ��= 'a This Permit Expires 1 Year From Date issued -!'-' - ------- ---------------- Application is hereby made to theSanJoaquin 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 existingps s and egulations: 00 Gc/ ENSRACT ----------- ------- JOB ADDRESS/LOCATION/�-j�" ---------- • 1. 1 ' Phone ------ Owner's Name ---- --- ----- --------------------------------------------------------------------------------------------- -,pp,,,,,,�� qq Address -------------- - -V-----" 0-7-A/1- --- City _l!_�-C�'Y_ - - _ "l--------------- Contractor's Name -- License # ----------------- ____ Phone _" -- ---- - -- } Installation will serve: Residence 0] Apartment House❑ Commercial:❑Trailer Court i❑ Other MQof �drooms------------------------------------ 'Motel "-_ _-------Garbage Grinder Number of living units:.__- Number der ----------- Lot Size f- ---�-r-�---`-�a� �'------ ----- --------- ---- ---------------------------------------------------- Private Water Supply: Public System and name _______________-______ --------------"-- - - El Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam Hardpan ❑ Adobe -&I Fill Material - --_-__ If yes, type --"------------------ - ---- :..�• - �1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) P seepage pit permitted if public sewgr is available within 200 feet,) NEW INSTALLATION: (No septic tank or ---------- PACKAGE TREATMENT [ ] SEPTIC TANK;] Size- - ----------------- qDepth V' " No. Compartments _rL_- -------•--= Capacity Y� f?Q---- TYPe��''-`'�----- Material__ ---- --- ---- =- � p I ` Foundation __/__6_ ----------- Prop. Line _ -------)------ Distance to nearest: Well ___� �----------------- ---- a I ---- Length of each line__._FV--------- ------ Total Length -- - LEACHING LINE [ ] No. of Lines ___".�----- ----- ------•- g �i --------- --_De l Depth Filter Materia --- + ----------•------- 'D' Box� Type Filter Material �'-�'-- -- P , Property Line �-------------"-"-- i Distance to nearest: Well __-��"-__"____.___ Foundation __/4?`-- SEEPAGE PIT [ ] Depth -----""---- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No .I❑ Water Table Depth -------- ----------------------------------- ----Rock Size -------------------------------- Distance to nearest: Well _ ------------------------I---------------Foundation -------------------- Prop. Line -------------•-------- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------- ----- --------------- Date --------------•-------------- ---] Septic Tank (Specify Requirements) ----------------- ------------------- Disposal Field (Specify Requirements) ---------------------------•-------------------------- ------------------------------------------------------------ - ---------------------------------------- - -------------------- ----------- ---- ------ -------------------- -------------------------------- (Draw existing and required addition an reverse si d e) 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: "1 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 .. T7GfYY --------------------------------------------------- Owner ------------------------------------ ------------------------------------ ----- - -- - --- - -- - ----------------------- - Title --------- --------- --------- -------- -------- -------- ----- (If other than owner) i FOR DEPARTMENT USE ONLY DATE -------- APPLICATION ACCEPTED BY -- --------------- ---------- DATE ------------------------------------------- BUILDING PERMIT ISSUED ------ "-"-- 1�------ --- �e *s.��.L-;J------- ADDITIONAL CO NTS -- - ----- -_---____ --- --------- - --- - - - --------- - _ - -------- -------- -------- -------- --------------------------- ----- ------------ --------------------------------- ------------ --------------------------- --- - ---------------------------- Date -- -- --------------------- Final Inspection by: ___ ------------- - ------" - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M