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4 EOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT 3 �� ;. y � ----`--;----------------=--------•---------- -- Permit onlplete in Triplicate) �[ p ------=---`---------- ----------------------------------- Date Issued 7__a�d_� � --------------------------- .--------------------_--- This Permit Expires 1 Year From Date Issued r 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 ._--- --_m -------.7------�` ------`gds'------- --"--- - CENSUS TRACT -------------------------- -------------------------------- -------------------- - - - ------- - --- Owner's Name ----_ 1------ -- - Phone -- �2_ -- ------------------------ Address ------------1 ---- I --- -----� t-------------- CitY - - ------------------ Contractors Name ---------C� G�IY-G=-=-�-� ---- - ? -------.License #e��_cfl j-'1y__ Phone - ---_ - Q - Installation will serve: -Residence,+Apartment House-E] Commercial :❑Trailer Court ;❑ Motel ❑ Other ------------------------------------------ e, Number of living.,units:----/10___ Number of bed ooms _Garbage Grinder ------------ Lot Size Water Supply: Public System and name ------ . ___-- -------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ ' Clay Loam:[] Hardpan ❑ Adobe EJ Fill Material ------------ If yes, type ---------------------------- I {Plot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must be placed on reverse side.) I ` NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) � PACKAGE TREATMENT [ ] SEPTIC TANK,f ],6-kiS7_/�ize------------------------------------------------ Liquid Depth ----_-----------------.--- .� Capacity I----------- -------- Type -------------------- Material---------------------- No. Compartments .-----------------=---- Distance to nearest: Well ------------------- _______Foundation _ -------------------- Prop. line ____.__.____.__.____._ LEACHING LINE ]` 'No. of Lines .-f_ __-..-.-.-.`_.-- Length of each line----,_0-- T&tal Length ------�Q.�..______.__ rr 'D' Box __�! ----- Type Filter Material _� -----Depth Filter Material -- _ _______________________________ 'Distance to nearest: Well ----�-------__-- Foundation ----- Property Line_ -d----_______________ SEEPAGE PIT [ ] Depth ....1--------------- Diameter -_--_______.__. Number ---.--------------------------- Rock Filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size --------------- ------•-------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------.--_. I ' REPAIR/ADDITION(Prev. Sanitation Permit# '---'-......------------------'------------- Date ----------------------------------) SepticTank (Specify Requirements[ ------------------------------- '=_---------- -------------------------------------------------------- -------------------------------- Disposal Field (Specify Requirements) -____Q' ll 111h .: f – - -------- ------------------------- i _,,. ' I — 9{Draw existing and required addition on reverse side) ; - b F 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 "1 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." k Signed ---------------------------- -------- ------------------------------/----------------------------- Owner By --------- � �Fca Title ' ----------------- (If other than owner) Y R DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY -_.__ ._ ____ . __ __ _ _ __________________ -------=t ------=-------. DATE _"_. . --7—f,-- f------------ BUILDINGPERMIT ISSUED -------------------------- ---------------------- ------ --------------------------;------------=--DATE -------------•----------------------------- r ADDITIONAL COMME=NTS --------- ------------------------------- G - ------'-----------------------------------------------=-------------------------------------------- ------------ '----'-`--------------------------------- --------------------------------- - --- - -- !'------------- ------- ------------ ------ - - - - - --- ----=------- Final Inspection by: -- --- ---------------------------------------------------------------- .Date �/ .a SAN J AQUIN LOCAL HEALTH DISTRICT } # E. H. 9 1-'68 Rev. 5M.