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FOR OFFICE USF: 'APPLICATION FOR SANITATION PERMIT 2 Permit o. Vl\ (Complete in Triplicate) ----------- --------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued .__..Ll-7a 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 -------- --- CENSUS TRACT .......................... Owner's Name --- —,2AW-l<--------- -- - -` -- ---------------- -------------------Phane Address ^ /1 i� 4 -------------------------- City -1--1 lm-M&- -------------------+�-------------------.-- Contractor's Name �I - i - _---e------------------- License Phone Installation will serve: Residence [;7Apartment House,❑ Commercial ❑Trailer,Court i❑ Motel ❑Other -------------------------------------------- Number of living units:------------ Number of bedrooms _______Garbage Grinder ------------ Lot Size 19-c _-_e- Supply: Public System and name --------------------------------------------------------------------- •-----•---Private X Character of soil to a depth of 3 feet: Sand$ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;❑ 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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK,[ ] Size__ --------___________________--_-_. Liquid Depth -______-__---___.-.- Capacity -------------------- Type ---------------- -- Material---------------------- No. Compartments ------- ---------•-•-- N Distance to nearest: Well ________-___ _____________________Foundation --____--__-______ Prop. Line ____._.__..._........ LEACHING LINE [ ] No. of Lines --_-__-_-_-__ Leng of each line---------------------------- Total Length -----------------------_-- 'D' -_----___--_-_-•----- ____ (u o D' Box ___________ Type Filter Mat ial --------------------Depth Filter Material ___________________.__.__._...___._.___.._ Distance to nearest: Well ______ --------------- Foundation Property Line _____...:.............. , SEEPAGE PIT [ ] Depth ____- Diamet ________-_____- Number _________________________ Rock Filled Yea ❑ No i❑ Water Table Depth ---------- ------------------------------------Rock Size -------------------------------- Distance to nearest: Well _______________________________________Foundation ___- --------------- Prop. Line ....___.._.......... REPAIR/ADDITION(Prev. Sanitation Permit# ___ ___________________________ ......... Date ___-_-__-_--_-__-___---------__-__) Septic Tank (Specify Requirements) ----- ________ Dis sal Field (Specify Requirements) ----------------- -!_._- -- - --------- ------- ----------- - !__sS - _ a <�✓----------- - 6-119 'Ilei----------- ----- (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, 1 shall not employ any person in such manner as to become subject to Workma 's Compensation la s of California." --- - - Signed ---- ----- ----- - ------ •-- ---------------- Owner BY -" ---------------------------- Title -------------------- --------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _.__ -_V_'u"^ - - - - ---------- -- ---. DATE ____T-1'- .___._ ---------------------------------- BUILDING PERMIT ISSUED ___________________.----------------DATE ------------ -------------- ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------------- -- ,p - - - - - - - - ---------------------- Final Inspection b _F___ U-------------------------------------------- ----------------------------------Date _'._ g-� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M