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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.., n----- --- .-. . .. . .. � '-""(Complete in Triplicate}----' "- '"""-` - """ I � ' ---------------- ------------------------------------ 7 Date Issued 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 thei work hierein v described. This application is made in compliant -with County Ordinance No. 549 and existing Rules and Regulations: ---------------------- JOB ADDRESS/LOCATION . _ `----- ----------------------------------------- ------CENSUS TRACT Owner's Name ------- L' -- ------ `= -------------------------------- --------------Phone d __�� Address ------ -- Cit � ----------------------' SSI �G3 Contractor's Name l ��------------------ Lam"` 'License # _.`�__.. Phone 3 Ir Installation will serve: Residence [AApartment House,171 Commercial ❑Trailer Court s❑ Motel ❑Other -------------------------------------------- i Number of living units:-.-_ ______ Number of bedrooms _____ ge Grinder ----____ Lot Size _-- --/!---1----U-- ___Garb 3 Water' Supply: Public System and name --------------------------------- Character ------------------- - Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat ❑ Sandy Loam ❑ Clay Loam Ej I Hardpan ❑ Adobe LK 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,), ----------- KA p PACKAGE TREATMENT { ] SEPTIC TANK'[ ] ^^ "� Siie: ------------------------------------ Liquid Depth _-- '--- .----• ,a_ Capacity _------ Type -------------------- Material---------------------- No. Compartments :-----•-_-•-----..--.. p Y ---- ----- Yp Distance to nearest: Well ___________-----------------------Foundation .___._____--__________ Prop. Line ___.______------._.--- LEACHING LINE [>( No. of Lines -- J� - --- Length of each line.-----�V-Q------- Total Length --------- -------------- -• 'D' Box -----/------ Type Filter Material --------!-"---Depth Filter Material ----- ----•-------•- ---- Property Line -'- ----- �� •- _ Distance to nearest: Well ��-----�---Foundation-:-.-��-.Jr--Q----- --- SEEPAGE-Mr , j Depth ______ l Diamete �_ ��-- NurrEbeRock Size __ y�'_� Rock Filled Yes j ' ,"No '�] Water Table Depth ------------------ --------------- / i � Distance to nearest: Well _______ --------------------------------Foundation f.2�--------- Prop. Line---—---_ -------- REPAI ADDITION(Prev,Sanitation Permit.#'-w- ------------ ------------------------- --------- ---- ---- Date ' - 4------- --------'A/10------- jSeptic Tank (Specify Requirements)_-_` 'fir= '� � "`� M e______________ P_____________- /Disposdl Field {Specify Requirements} ____,_______ __ ' ? --------------------------------------------------------------- ----------------a----------------------...,1. = ': t'``=---------- -------�--------------------------------------------:.=------------ ---------------------------------------------------- ---------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1. Kave prepared this application and that the work will be done in accordance with .5an Joaquin Count'.brrdinances, State Laws, and€Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- I 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 I 1 i igned. -------------------'= ----- Owner / f�. - ------------- / ------- -------------------- By Title ------------------ (If other than owner)1�17 F~ FOR DEPARTMENT USE ONLY 1_ - APPLICATION ACCEPTED BY _------------ -------------------------------- ---------------------------------- DATE --- /- ___f1- 71 BUILDING PERMIT-ISSUED ----------------------------------- ----DATE ------------ - ADDI710NAL COMMENTS ------------r- --------------------------------------------------------------- --------------------------------- -- -------------- . ----------•- ------------------------------------------------------------------------------- ----- ------ ` i -------------------------------------------- --- '(--t - Final Inspection by: - -- ___- _-___ __ --__ _ _--._.__ jE� -----��•.^--_------------- - --- SAN JOAQUIN 'LOCAI:-HEALTH"DISTRICT E. H. 9 1-'68 Rev. 5M