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F_C?Q OFFICE USE: f APPLICATION FOR SANITATION PERMIT --------------------- ------ ] 5 -- -------------�- (Complete in Triplicate) Permit No. --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued ___�--- _--"_7 z' 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 --__ --------------------------------------CENSUS TRACT e-----------1- -D------ Owner's Name ----4/n --------------------- ----- ---------P one .- ---- Address o� - - --- ----- ----------- ------------------------ City --------- - - -- ---- -----------------Contractor's Name --__ _ ___ _____ ____r____ --------------------License # 25��___ Phone Installation will serve: Residence 5KApartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑ Other .------------------------------=------------ Number of living units:----j------ Number of bedrooms ______Garbage Grinder. --- Lot Size _ Water Supply: Public System and name -------------i:1 ------- •------i-----.----------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt::❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe>d 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,) PACKAGE TREATMENT: [-] SEPTIC TANK] Size_______*—Y-10------------------- Liquid Depth ____ ° . .......... l..i Capacity/1�2"- O-L- Type -- f '---------_ Material-&�� 4e—No. Compartments ---- VV / r i Distance to nearest: Well _-----1166/-&,--------------Foundation __140_______------ Prop. Line _ --____:________ LEACHING LINE No, of Lines ____ ................ Length of each line--&W ---------------- Total Length ._____-- D' Box _ Type Filter Material _ �` 'a Depth Filter Material ___�p.. ................... . ....... Distance to nearest: Well R'4 ------- Foundation ___ V Property Line - ______________ SffP,44&&+tT J Depth __ ___ Diameter -------- Number ----------/______________ Rock Filled Yes [fi No.I❑ Water Table Depth ----------------��4?---I-------------------Rock Size -------.2---"�------------ Distance to nearest: Well ---------_"---r__________________Foundation --------------------- Prop. Line --------..____.___---_ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date _____________--___--__-_________-} SepticTank (Specify Requirements) ----------------------- - ---------------------------------------------------------------------------- ---- ---------------------- DisposalField (Specify Requirements) ------------------------------------------------------------------------ ------------------------------------------------------------ ---------------------------------- ----------------------------------------------------------------- -- -------------------------------- ------------------------------------ -------------------- (Draw.existing and required addition on 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, I shall not employ any person in such manner as to become subject to Workman's Compen3ation laws of California." Signed --- ------------------=-------------------------- ---------- -------------- ------------------- Owner By - than owner) -- - ------ ---------------------------------------- Title ---- ---------------- (If other FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _._7--- ------- 7 ------------------ DATE --- -�-�/----17 --- BUILDINGPERMIT ISSUED --------------------------------- --------------- ------------------------------- -------DATE ------------- --- ---------------------- ADDITIONALCOMMENTS ------ ---------- --------------------------------------------------------------------------------------- ----------------------------------------------------- ?5M7 -- ----- ------------ ------ - ---------------------------------------------------------------------------------- ------------ -----------------------------=------- Final Inspection by: - -- ---------------------------------------------- --------------------------------------Date _.. ^SS N JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 R