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FOR OFFICE USE: f 3 0. ..-.... APPLICATION FOR SANITATION PERMIT `— ........ ..... -, - - - �� n .s (Complete in Triplicate) Permit No. ............. ..................... ......... - ......................................... This Permit Expires I Year From Date Issued Date Issued .......�' �S 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: 10 17 7 0 JOB ADDRESS/LOCATI d / .. .- .......... --------- - -- - - ........CENSUS TRACT ...---................---- 111" Owner's Name . --�- ,„�---- ..Phone ..770..... ------- -. . . Address . .......... .......... -. ----------- -- •----..------ I........... city ....... ... ....-- --....._......_......................•-------- Contractor's Name _. ._. W .L4!-!1.. .....!�.....................License # '. .`1.3--.---- Phone ..7.__... Installation will serve: Residence Apartment House-E3 Commercial ❑Trailer Court 0 MotelOther . ...... ........ ... _-..--------------- r Number of living units-.. ..t.... . Number of bedrooms ...3---..Garbage Grinder . . Lot Size _93... ........................... Water Supply: Public System and name .......:-...........:.:.------------- ..-..---....--- ._t'C.CI-e.-C,... ... Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Cloy ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ Hardpan ❑ Adobe Fill Material If yes, type ..... .................... . ----= ---- �_--___i - - - - -- — (Plot plan, showing size of lot, location of system in relation to wells;�b .Ildings, 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[ I Size.--,.._.--_---------- � Liquid Depth ................ --� Capacity . ._.__ Type,_..-_.....- Material..... k .. No. Compartments ...................... - - ---- - - ---------T Foundation . Distance to nearest: Well _ _ . Prop. Line _____________________ LEACHING LINE [ ] No. of Lines r� ._.. . ._Jength of each line s Total Length ---------------- - -D' Box , .±._Type-Filter Material _t_x-_•--:._._r ..Depth Filter Material 4-------- D 6 istance _._::Distance to nearest: Well ......................... Foundation .......... .. Property Line ---------•--..-.--.....- SEEPAGE PIT { j Depth Diameter -------------- Number .. . ......... Rock Filled Yes ❑ No ❑r= Water Table Depth -------------- -- ...........___--------------Rock Size ---------------••----•-------.. Distance to nearest: Well ---------------_-- - ---Foundation _ .......... ....--- Prop. line ...................... REPAIR/ADDITION(Prey. Sanitation Permit# ........ ... ........ ..................... Date ___..-.--_..._--.----.----_-.-.---) Septic Tank (Specify Requirements) - -. . - - _ Disposal Field (Specify Requirements) ..... ........_..._-_ . _ _-- --_.-- -_ d.G �GtKR- .. ----......... .. .......... x_.33..” x . ` ,f��r . .. -�% _........I....... . ...................... - -------- -. .. ....... .... .. ......... ............. ... .-...----- . --- .------......_.. ....--- .. {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 Son- .Joaquin Local Health District. Nome 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 .:.. . ... ...... ......... Owner ..... - By Title _.. (If of er tha wner) OR DEPARTMENT USEONLY APPLICATION ACCEPTED BY . _ .. ..... .. .. .. DATE ..��... --� 7.5- BUILDING PERMIT ISSUED __.... . .... - ..DATE . ... ....... ....... ...... ADDITIONAL COMMENTS .. . . .......... ............................. ------------- ------ . ...-..----- ti: :.. .... .....-- ........_. ..------...-, -----............� . . ..� ---.... .. �.,4................... Final Inspection by: -- .....----------------Date ._. ... :.... ..................... SAN JOAQUIN LOCAL HEALTH DISTRICT G. E. H. 13 24 1-'68 Rev. 5M1.4 72 3 4