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FOR OFFICE USE: �� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) - - Date Issued ___ -------71 --------------------------------------------------------- This Permit Expires 1 Year From 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/LOCATIONj? ___ -------------------------------CENSUS TRACT --------------........... j Owner's Name -1fl..S---------------------------------------------------=--------------------PhonewJ 3-3-3-4r46 --- Q Address 7_Q-- -} /.. �r�/l�• I---------------------- --- City _�_I_1�t_� ---------------------------------------------- Contractor's Name __1_.c, /1±�-----------------------------------------------------------License , Phone-�-�: Installation will server ' Residence (<partment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other ---------------------------------------- Number of living units:---- ----- Number of bedrooms -.1-----Garbage Grinder ___ Lot Size1Q�A-0- !=_____`________________ Water Supply: Public System and name ----------------------•--------------------------------------------- ------------------------------------------Private Character of soil to a depth of 3 feet: Sand'[SiIt❑ 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 --------- ------------ 1 -----__. —.Foundation Distance to nearest: Well =--Len Length of each ime-__ To Prop. Line ______________________ LEACHING LINE [ ] No. of Lines ______ _______ g Total Length -----------,________________ 'D' 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/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ------------------------__________) Septic Tank (Specify Requirements) ----------------- --------------------------------- ------- ------------------- ---------------------------- ox -------- ---- �g - Disposal Field (Specify Requirements) __ - / D{S 1"�i-6'v a/��x_7 •�`X/sra� � '— ----------------------------- - ----------------- ------------ -------------- QP__`_ a� _�l'.Ei3' �T"_ •gE`-E -- GTi '"�- '_-�'c��`-----__------- (Draw existing and required addition 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 Regulationsof the San Joaquin Local Health District. Home owner or licen- s4agents 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 `,,_qs to bec*e subject to Workman's Compensation laws of Ccllifornia., Si ned ______ _-__ -_ .. A___ Owner - --- -------- ----- 1 ' ------------------ B --------------------------------- - ,__ Title�G /?�•C�O�'( ��/!�" --- -- ---- ( f other than ow 4,2 FOR EPAitTMENT USE ONLY APPLICATION ACCEPTED BY ---- '------------------------------------------- -----. DATE --- - BUILDING PERMIT ISSUED -------------------------------------------------------------------------------------------=-f--------DATE ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------ -------------------------------------- -----------------------------------------------------------------------•--- ------------- ----t .;----------------------------------------------------------------------------------------_- ------------------- ------------- ---------------------------- ---------------- -------- ------ Final Inspection by ---- �----=-�` -------------------------------=-------- - ------- --------------------Date -----�%v-----------L--------------- SAN JOAQUIN LOCAL HEALTH.'DISTRICT E. H. 9 1-'68 Rev. 5M