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FOR OFFICE USE: APPLICATIJtJaF�lR SANITATION PERMIT -- �W — Permit No: ------------------- (Complete in Triplicate) -------------------------- ---------------- !J_ ---------------------- ', This Permit Expires 1 Year From Date Irbued Date Issued -.I--.I 7� 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . 1 ---%3�*'1-C' -4-ei;A--------------- ------ ---- -- ----- CENSUS TRACT -------------------------- Owner's Name - *--- �& --F----------------------------------------------- ----a- ----- --- ---.-Phone city,.7_ y-� t Address --- ---- r ��-��";---- ---- ------------------------------------------------- -- �/� �rw------------------------------------------ G� �d�-------------------------------!icense#��? Z Phone -� Contractor's Name ______ �__ -. Installation will serve: {Residence *19partment House ❑ Commercial ❑Trailer Court !❑ ] Motel'❑Other --- ----------------- r f Number of living units:--- Number of bc� r��ooms __1—___Garbage Grinder -._ Lot Size f. - -�_ �-------------- Water Supply- Public System and!name _ ((1 _ / (' i,[ ' �r�' _____________________________________Private ❑ + Character of soil to,a depth.of 3 feet: Sand'❑ Sllr;❑ Clay [❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobeill Material __----- -- if yes, type --------------------------- (Plot plan, showing size of lot, location of system in relation to wells, labildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No sep4 tank or seepage pit permitted if public All is available within 200 feet,] PACKAGE TREATMENT { ] SEPTIC TANK [ ] ' Size-- ------_---�}'--------------------------- Liquid Depth _---------_----------.-.._. Capacity -------------- ----- Type -------------------- Materia)'';----------------- No. Compartments. ------ --------------- . i Distance to nearest Well = Len line.,Foundation ______________________ Prop. Line ---------------------- LEACHING LINE [ ] No. of Lines ___ . rgfih of each ------ --------------------- Total Length ----------- ---------------- 'D' Box _-_--------- Type Filter Material -------------�_�J__Depth Filter Material ________________-___-________--..,_--____-- g Distance to nearest:`Well ________________________ Foundation ------------------------ Property Line _-__-__.__--______-____- r, SEEPAGE PIT [ 3 Depth ___________________ Diameter ---------------- N-unibe ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth -----------------------------------11-------- ----- ---Rock Size ---------------- --------------- 1r Distance:to,negret_yWe�l_ _____ ___ _ __ _ __ �_____ :}_ _Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) r Septic Tank (Specify Requirements)t_`---. -- -------------------------------------------- --------------------------------- - --- --------------------/ ---------------- ------------------------- _ •- Disposal Field (Specify Requirements) --- ---- " ------------------------------- -------------------------------------------- ----- (Draw existing and required addition on;reverse side)__ ., I hereby certify that I have prepared this application and that the work ywill 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: 1 "I certify that in the performance of the Wo-i for whiih ihis perm`if4 issued, I shall not employ any person in such manner as,to become subject to Workman's Compe sation laws of California." Signed --- ------ -------- --- --- ---- ---- --- --- ----- ---- --------------'--- ------ Owner BYTitle ------------------------------------- (If oth an owner) ` .. 6 FOR DEPARTMENT USE ONLY ,. APPLICATION ACCEPTED BY -- --- -- -------- ----- ------------ ------- --- - -' --- � DATE ------------------------------------------- BUILDING ---~-- -- ---------------------BUILDING PERMIT ISSUED ------ ---------------------------------- ------------------------ -------------------------------- --------- ---_---------------- r ------------------------ ----------- ADDITIONAL COMMENTS ------------- ------------------- ----------------- ------------ --`-----------------------------------------`- = --------- -------- \ A ___________________________________________________________________________________________________________________________________________________________________________________________ ----'-----------`------------------ ._ ____-__ ----- Final Inspection by: _. ----- - ----- -- - ------------------------------ SAN �--�C7--�� -- ------------ --'-'------------------------------------- --------------------Dote _...--------- - - ------- -- ---- _41, - ° SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 -11''68 ev,5M � 9�.„ ., i