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3 FOR OFFICE USE: s. Permit No. APPLICATION FOR SANITATION PERMIT ' (Complete in Triplicate) 3 v 7L --- -----=-------- --------------------------------- Date Issued ------=-Z----=--- -------------------- This Permit Expires I Year From Date Issued — --------------------------------- X 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 unt Orrddi�nce,�loo 54Aand existing Rules and Regulations: JOB ADDRESS/LOC 10 1 Q _ � 4� 5US TRACT i� ----- ------ - - �------ -----Phone -��.��,�-�------ Owner's Name ___ -- -- - - - -- Tt- fl City Address , -------------------------------------- � - - 4 _ 11__C -1- //-- --1 6C-- Contractor's Name __ _ _ -�)_ _ ,___.License # _--� -- Phoneiv Installation will serve: Residence KApartment House,❑ Commercial :❑Trailer Court ';❑ { Motel ❑Other -------------------------------------------- Number ----------------------------------- - Number of living units:___)--_--- Number of bedrooms .-- --_Garbage Grinder ---0----- Lot Size ___—T_ rrz------------------ I Water Supply: Public System and name _____________________ } ' - Private [� - _= - --- -- Character of soil to a depth of 3 feet: Sand' Silt ClayPeat ❑ Sandy Loam 0', Clay Loam;❑ R - r Hardpan ❑ Adobe'❑�.Fill_Material--------------if.yes, type ---------------------------- ( plan,lan, showing size�of lot, location of system in relation to wells,,buildings, .etc. must rbe placed on reverse side.) `O I NEW INSTALLATION: (No septic tank or seepage pit permitted if public'sewer is available within 200 feet,) SEPTIC TANK f Size-------------------\----- -------- ---------�- Liquid Depth ---------------------.----- PACKAGE TREATMENT [.j [ l , � :- T I,r �� Nor Compatments ------------- Capacity ----------------- Material--- -------------- --- -------------- TYPe r Distance to nearest: Well ------------------------------------Foundation _____.__-_l.-_------ Pr p. Line ___.____-- `- y LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---•--' °----------------- Total L`engfih ------------------------•--- 3 `D' Box ------------ Type Filter Material --------------------- Depth� - ___Fil#er Material ________#_ �_ ---------- V . 1 ' +i•` °Pro�r Line ------------------------ Rock ---- ----- Distance to nearest: Well �-A�,------__-- Foundation-------------------------I, p, tlL ., ----•------ SEEPAGE PIT [ ) Depth -------------------- Diameter; ___' r.____-- Number ----------------- �-_-- 1Zock'Fill;ed Yes [3 No �] , me Water Table Depth ------------.;--:---�f- - _ ck.Size Jam. _ y�`f q,. Y ti -- ----•-- - -� - y Line Jl� Distance to nearest: Well �----1 �------------- •-- Foundation p• _ 1 I REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------- -' -Y: { Date __ ----.-----------------) r r _) 1 Septic Tank (Specify Requirements) -------- - ----- --- ------ Disposal Field {Specify Requirements) _ - --- - - - ---- -- ----------- ----------------------------------------- _ ------------ ----- - --- ------ -- --- -� -� - r� "- ----(Draw`existin 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 Regulations of the San Joaquin Local Health District. Home owner or liceri- 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." I 1�' _____ Owner ISigned ----------------------- -------------------------- t � �3' -v+�'-- Title ---a -- --------------- ----------=--------- (If other t owner) FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY -----` ------------------ --------------- - - --------------- ------- ---------------- DATE ' -- --- BUILDING PERMIT ISSUED ---------------------- -------DAT ADDITIONAL COMMENTS ----------------------- - ----------------------------- ------- ------------------------------------ ----------------------------------------------------------------- ---------- s' - -k- 4&- Final Inspection by: Date �;. SAN JOAQUIN LOCAL HEALTH DISTRICT + E. H. 9 1-'68 Rev. 5M