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FOR 05CICE USE: APPLICATION .FOR SANITATION PERMIT. .n -------------------- --------- ----------- ------------ �it1 L, 'a � P-erm.it.No._--_,.1 �_Lf3 (Complete rn Triplicate) ---------------------------------W----- I Date Issued p------------------- This Permit Expires 1 Year From Date Issued - Application is hereby made to the San Joaquin Local Health District for a permit to construct 6d install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. t JOB ADDRESS/LOCATION c � �..a- - - ------- t CENSUS'TRACT Owner's Name --- - - =----------------- = _ Ad -.Ph one , dress �.------ ---- ------ ---------- -- ------------------- -------- fity - - - -----' ---•- --------------- t Contractor's Name ------------------License #TI- ------ P one :01W07- 6'x.---.-- t Installation will serve: Residence�Apartment Houser] Commercial'❑Trailer Court // �� F. Motel ❑ Other ----------------------------------------------- •; I Number of living units:-.-- -_---- Number of bedrooms _-3---.-Garbage Gri der, ---- Lot Size Supply: Public System and name -�----- ----------------------- --'---- /r im-------_{---------_:`:•}-_-- _------Private [ICharacter of soil to a depth of 3 feet: Sand�❑ Sift❑ Clay Peat E] Sandy Loam ❑ Clay Loom Hardpan ❑ Adobe Fill Material -.---------- If yes, ---- L----- -------------- I s (Plot plan, showing size of lot, location of Isystem-in.,relation.to-wells,._bui.ldings, etc.-must,,,be.-placed.on rmyerse_side.) NEW INSTALLATION:• (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) J PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size____________________ `----------------------- Liquid Depth ----_------------ --- Material - -- -- No. Com P tments ------ ------- �� }} Capacity ------------- --- TY�I?e' -==-------------- - - - ---- P ---------------- Distance -----------• - Distance to nearest: Well - --' ----------------------------Foundation --------- -------=---- p• -•------- �+ g ,z 4p t 'De' the c LEACHING LINE [ ] No. of Lines ------------------------ Total Lengthy- ---------___-•. -------- t ,. — I.s D Box ------------ TypeAFilter 1174 er!al of each !--7 p`--,Filterj Material ----------------- '.--------•-•-,�-••-•--- Distance to nearest: Well --__tet _________ Foundation Property L-0.)_------- -------- SEEPAGE PIT [ ] Depth -------------- --- DiamefieF�_�---_-_------- Number ---------------------------- Rock Filled Yes ❑ No i❑ s 1 Water Table Depth -_ -------Rock Size -------------------------------- I Distance to nearest: Well --------- --- ----------------•--.....Foundation -------------------- Prop. Line -------------- ....... REPAIR/ADDITION(Prev. Sanitation Permit# ----- ` --------------- Date ------..-------_ --------------- R R r 15eptic Tank (Specify Requirements) -------- = ------------------------------- --------•-----------•------------•-------- - i Disposal Field (Specify Requirements - --------- ---------------------------------------------- -------- ------ ' - - - ----- ----- - t- - ; ------------------------- ------------------------------ --- --------------------------------------------- (Draw ------------------—---------------------� - E i (Draw existingand required addition on reverse side) I thereby 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 aicen- sed agents signature certifies the following: "I,certify that in the performance of the work for which this permit is issued;-I--sholl`n'ot--employ-any-person such manner /'?as to become subject to Workman's Compensation laws of California." V, `Si a ned ------ - Owner BTitle ---� --------------------------------------------------------- _.. -- - - - - -- ---------------------------------- (If other than .owner) r F R .DEPARTMENT- SE'ONLY ' APPLICATION ACCEPTED BY --- ------------ --- ------- -----. DATE ------A` 1 --,11 t_ - ----- r- ----- -BUILDING PERMIT ISSUED ----- - -------DATE ---------------------------------AbDITIONAL COMMENTS.-----' `--------------------- ------- -------------•------------------------- -------------------- ------------------------------------'-------- -------------------------------------------- ------ ------------ -- --le: -- _ ; ;-- --- - -- -c -- ! Fi'rlal Inspection by. -----.Date ----------------------------------- ------------------------------•-------------------------- -- ---_:------ ------------ -�79 [ SAN JOAQUIN LOCAL'HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M