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-FdR OFFICE USE, `^ .. .,; ........ APPLICATION FOR SANITATION PERMIT k (Complete in Triplicate) Permit No. .:- .S:3�.3 S k 7S .............. ••-- _��- This Permit Expires f Year From Date issued Date Issued ............:. Application is hereby made to theSonJoaquin Local Health District for a permit to construct and install the work f. described, This application is made in compliance with County Ordinance No."549 and existing Rules and Regulationsrein I JOB ADDRESS/LOCATIO `(� C✓ ....... --" Gcc'``� CENSUS TRACT Owner's Name .... .. ..............._...:....._ Address -._ ..P one ... I Contractor` City s Name . -- _ 'ti�� u�. , ..License # Installation will serve: ) ` . Phone Residence Apartment House Commercial [Trailer Court ❑ I i Motel ❑Other ...__...... Number of living units:... /. Number of b roams ..- Water Supply: Public System and name ..... -. Garbage Grinder .- - LotSize .1 X pp Y: - � - . .. -_.. _ Sand ❑ Silt❑ Clay Private Character of soil to a depth of 3 feet: ❑ i Y ❑ Peat❑ Sandy Loom ® Clay loom ❑ kHardpan ❑ Adobe Fill Material ..... If Yes, type .......................... (Plot pian, 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 .....�................. Ca aci -- A ty coda ;ype - ateriol - o. Compartments .- - y� U .......Foundation -` -.`....:..- Prop. Line -..-a5�'..�.....- .... Distance to nearest. Well LEACHING LINE fS AOY 9nes W � . ..T ... --- ..... Length of'each line............... ............ Total Length --.....-..._. 'D' Box ....1 ............... Type Filter Material----------- -------Depth Filter Material ..-.. - .-. ..-. - O r DistQnce to nearest: Well .............. Foundation .-.....- CY 5EEP�AGE PIT IS r6eeppt"h6' --:-. Property .Line ........................S .. .. .. ........ Diameter -..-._-- Number . ....... ..:...,---,------- Rock Filled Yes ❑ No Water Table Depth -..---•-•�-•----•---------•- ...........Rock Size .------- ---------- Distance to nearest: Wel! _..-_...�-------------------------------Foundation ..... --.... Prop. Line - ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ------ ------ --- - ------. ................. Date ------- Septic Tank (Specify Requirements)'-... r Disposal field (Specify Requirements) -..•__,.__ l (� ` --• ..... -- --• ---- --•- --..-...--- :. ....... •.................. .... ...................... (Drdw existing and required addition on reverse -ido) 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 I shall net employ an { as to become subject to Workman's Compensation laws of California." p y Y person in such manner Signed ------ --- ------------ - Owner 8y Title (If other than owner) k fFFOJL DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...`.-- ... _ BUILDING PERMIT ISSUED ..... . . .......ADDITIONAL - ----------------- --•. .................................................. -••-.----•-------------------- -------------- ----•---------- --- ---•-- --.....-_..._.... ------•---------..-------------....--•----- .........- ------- ----- - --- --- - -------- ------ Final Inspection b p y: ...- j . .. - .- .----� �-- -------•- - �----•---- ----• -- - ----------Dote ....-. . �_ SAN JOAQUIN LOCAL HEALTH DISTRICT E, H:13 24 1.'68 Rev. 5M