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FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT Permit No, (Complete in Triplicate) -------------- This Permit Expires I Year From Date Issued Date Issued _--__.__.___._--_-- 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 LOrdinance No. 549 and existing Rules and Regulations: JOB'ADDRESS/LOCATION ---------1-14do---------`' -------- -f---C- ---------- ------------------- -----CENSUS TRACT --- ------------------- Owner's Name -----` 7L4---'0. --U-r---e-S------------------------------------------------------------ --------------- ---Phone —41Zo 46�,---- Address --------- ------------------/------------- -------------------------- ------------------------------. City ---------- -------------------------------------- Contractor's Namet�--)�3n-k--------License # Phone ,44 _111!6/A __. r Installation will serve: Residence R'Apartment House❑ Commercial oTrailer Court ',❑ Motel ❑ Other -------------------------------------------- Number of living units:----- Number of bedrooms -----2---Garbage Grinder ------------ Lot Size ----------------- Water Supply: Public System anti name ----------- -------------- --------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'o Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan Ej- Adobe O� 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 tank or seepage pit permitted if public sewer is available within 200 feet,) If PACKAGE TREATMENT [ ] SEPTIC TANK 01010, Size_____ P------------------- Liquid Depth ___��_____--------- Capacity --- Type --`a4c4W)t-Material.-Aro& -----.- No. Compartments _____ ~._...__-__- f p ` Distance to nearest: Well ........Cr_a_ _ ______________Foundda//tion Prop. Line ___ ------________ LEACHING LINE De No. of Lines ----------/----------- Length of each line------- I ------ Total Length __ __f.__._______- 'D' Box ---- Type Filter Material ------I_ ____Depth Filter Material --------/ ___-__________________________ Distance to nearest: Well -------7f1------.___ Foundation ____--_�_---------- Property Line ----,CQ------------- SEEPAGE PIT Depth ___._ - !__ Diameter _-SS If" Number ._____._.---�_____________ Rock Filled Yes Lf No 0 Water Table Depth -------------- -- -------------------Ronk-Size ---------------------------- Distance to nearest: Well ----___1414_ _________________Foundation ------ Prop. Line ..... QK REAI_ DDIT16-41prev. Sanitation Permit# -------------------------------------------- Dctte�___'y______________--..--___-----1 tic Tank (Specify Requirements) ` Disposal Field (Specify Requirements) ___---___________1;6_U_ __ ____ ----- --f�1J ------------------- -------------------------------------------- ------------- ------------- ---------------------------------------- --------------_------------------------ ------------------- -- --------------------------- -- - - -------------------------- - - -- ------------------------------------------------------------------------------------------------------- (Draw existing and required addition bn 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 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------------- --------------------------------------------------------- Owner BY -------- --------- Title ---- - ---------------------- - ----- --- - -- - - - - --------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYlq\ DATE ----».--. _'Z ------------------ BUILDING. PERMIT ISSUED --- ---- ------- -- --------------------------------------------------DATE-._----------------------------------------- ADDITIONAL ---;---------------------------- --- - ADDITIONAL COMMENTS ------------------------------ -- --- - ----------------------------------------------=--------------------------- ------ ------------------------------------- - ----- - ------ - ------------------------------------ ---------------------------------------------------------------------------- ---------------- - - -- Final Inspection by: ---�- Date ` 5-1 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1•'68 Rev. 5M