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FOR OFFICE USE: ,...APPLICATION FOR SANITATION PERMITd � Permit No. - --0G -_�- /3� / ----------------------------------- (Complete in Triplicate) Date Issued - --�--------- - Y 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 11 described. This application is made in comp)' nce with Co ty Ordinance No. 549 and existing Rules and Regulations. i 0k A JOB ADDRESS/L CATIONd.1-Q�j 10, � ---CENSUS TRACT -------------------------- �cLC� Phone 6-_- -- Owner's Name ----- -- ------------------------ �! = t ------ City - --------- --------- ------------- Address - ----------- f Contractor's NamA �\c EC- +�� i License # " Phone 4 Installation will serve: Resi encs VQApartment House❑ Commercial ❑Trailer Court ❑ Motel ❑ Other ---------- --------------------------------- � 1--------- ------------ Number of living units:--- __.___ Number of bedrooms _,i------Garbage Grinder -__.-.-____ lot Size _.__._:_-- Water Supply: Public System and name ---------------------------- ---•-- --------- --------- - ------------------------------------- Privafie Character of soil to a depthpf 3 feet-.-�Sand'❑ Silt❑ Clay ❑ Peat ElSandy LoamClay 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 to fk or seepage pif4 ermitted if public sewer is available within 200 set, sr r SEPTIC TANK ,K Ir _ Liquid Depth --a PACKAGE TREATMENT =[�] ! Size--,K ----- - __" No. Compartments ---. +--"...--=---- Capacity ��+�-�.�------ Type Material_ P Foundation ---/-_�U 1------- Prop. Line _-- .. FDistance to ,nearest: Well -�.l��?____------------------ t LEACHING LINE [ ' `No. of Lines Leng#h of each line____ --------------- Total Length -sem - --- ----•- p,►i ii ! - Box..___I-��.�"" Type Filter Material` - V. _"_Depth Filter Material _�__ _." - { ) ' -- Property Line Q_F__...- 4_"Distance to nearest` Well ----------- Fou, anon �.Q-------- p tY . • SEEPAGE PIT [ ] I D .pth "' Diameter ,_________------- Number ---------------------------- Rock Filled Yes El No ❑ -- ---- ---- % WaterTable Dept ------------------------------------------------Rock Size .--.------------------ ---- x ; Pro Line --------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------- Distance to nearest: Well ----------------------------------------Foundation -------------------- p• -------------- Date ------------------- ------------ ) ----------- - - Septic Tank (Specify Requirements) -.:---- ------ : ----------------------- Disposal Field" (Specify Requirements) ------------ ----------- ----------------------------------------------- ------------------------ - ------------------------------- ------- : 1-i ---------------------------------- (Draw existing and required addition on reverse side) I hereby certify that;l 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 not employ any person in such manner as to be ub�ect to orkman'slompens n laws California." 1 � Signe--- 4�.� ------ ----- ------ --- ---- -- -- - ------ --- ---- Title ------ --- ........... -- ----- ----" -------- --------- By ------------- - r - (If other than owner) G FOR DEPA TMENT USE ONLY APPLICATION ACCEPTED BY ------------ - ---------------------------- DATE ------ ----- - - ------------------ ---- ----- ----------- ------- ------ DATE - -------------- --------------------- BUILDING PERMIT ISSUED -- -- -"-- ------------------ ADDITIONAL COMMENTS !l ° 4 -�3 - --- --------------------------------------------------` --------------------------------------- --- ------------------------ --- ----- ----- -- ----- - ---- ------------------------------- ------------------------------------------- ------------- {� --� -- ------. ate ------• --- ----- -------- ----- - - Final Inspection by --- - - ------ ---- -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M '