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FO[Z OFFICE USE: i' APPLICATION FOR SANITATION PERMIT (, ' Permit No. _7I.1.�_a__T., (Complete in Triplicate) ----------------- � p Date Issued ' Issued This Permit Expires 1 Year From pate Application is hereby made to the San Joaquin Local Health District for a p6o to construct and install the work herein described. This application;is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: .' M -r, 4 SOX L 1.A►cd� �J , JOB ADDRESS/LOCATION ,�.� --- h-�- -- - `- ---- ''�''0- CENSUS TRACT --------- L * \t Owner's Name ___�oSS t ------------Phone-----------------------------------`�- iCitC_/ rl�. -c-a�----------------------------------------------- Address -------------/ L err . C�1 !� Y Contractor's Name ----- - ----- - ! License # _/.�_��Z --.. Phone --- d � --------- l Installation will serve: Residence partment House❑ Commercial :❑TrailerCourt ',0 Motel ❑ Other ------ ----------------------- ----- y 7�.-..Garbage Grinder ._ __. Lot Size . .. �e�...-- '�- Number of living units:____]--...-. Number of bedrooms ._ ' ' --- ----- `------ I Supply: Public System and name -------------------------- '- --------`------------- - ------.----------.Private 1 Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay-❑�"' Peat❑ " Sandy Loam ❑ Clay Loam.� Hardpan �ti- f p ❑ Adobe ❑ Fill Material------------ if yep, tYPr i (Plot plan, showing sizeof 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,] [ ] -------------- -� 1 SEPTIC TANK'[ ] Size - --- Liquid Depth - ----- PACKAGE TREATMENT �7 acit . Type--------------------- Material..-.- .-.._'___------ No. Compartments ...................... Distance to nearest: Well ------------------------------------Foundation ___----------- ----__ Prop. Line -.---------"------------ LEACHING LINE [ j No. of Lines -- --------------------- Length of each line --------------------------- Total Length ;---------------------------- 'Dl' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------.------------------ -•-.-- ` Distance to nearest: Well ------------------------ Foundation ____°-.-----_-_----------- Property Line_ ----------..-_._._.-._-- SEEPAGE PIT [ ] Depth - ------------ Diameter ................ Number ------------------- _-- Rock Filled Yes ❑ No Water Table Depth ---------------------------------------------Rock Size --------------- --------.------- Distance to nearest: Well ----------------------------------------Foundation ---------------•---- Prop. Line --------.._....-_--- REPAIR/A IIDION(Prev. anitation Permit# ------------------------------ _ _ ---------- -- Date ._- --------------------.`--------- Septic 1 (Specify quirements) ------=--------------------- - --- -- ---- ---------------------- / �� 415) "' Disposal Field (Specify Requirements)�.__._....._ .. ...... .... . i -='-------`-------------- J1. -_ L f ' --------------- __ `--------- -----:-------------- ---------------- ------- ------ (Draw existing and-required additibn on,'reverse side),, I hereby certify that 1 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- I 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." 4 ` Signed Owne B - - - - -- �� m_ , -- -- -- -- - - ------------------�- Title-- -• -v �� ------------------- (If other than o er ., F EPARTMENT USE ONLY h ., I - ----- DATE - ---------------- BU LAPPLDINGPERMIT ICATION CESSLIDEDBY = ----- ---- ---=-----'--j DATE ADDITIONAL COMMENTS'---- -- - `- ----- ' - ----------------------- --------------------------- --------------------------------- ----------------------------------------------------------------------------------------- ----------- -----------------------------------------------m-------- - ------ ------- ------------ Final Inspection b --------- __ ------- Date f 7 --- �� SAN JOAQUIN LOCAL HEALTH}DISTRICT G E. H. 9 1-'68 Rev. 5M