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FOR OFFICE USE: "424 1_10_! ! azn APPLICATION FOR SANITATION PERMIT Permit No. S- X (Complete in Triplicate) _______________•-- •- ------------------------------- -_-_-__________________ This Permit Expires 1 Year From Date Issued Date Issued _!V Application is hereby made to the San Joaquin Local Health District for a per 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 .--?- , --- /vL _/_.�f1 ---- -------------------------CENSUS TRACT -------------------------- Owner's Name ----��------ ---------------------- -------Phone ------ ------------------------•---- r Address -_4e.366-----lC --------------------------------------------. City ---------------------------------------------- Contractor's - - --- -----------------------•-•--- Contractor's Name -- f� E� c�1d✓;��ment ._ --_-License # ¢�7 _ Phone � '� ' Installation will serve: Residence House❑ Commercial ❑Trailer Court ;l] Motel ❑Other -------------------------------------------- Number -- ----------------------------- Number of living units:.--/---__ Number of bedrooms _______Garbage Grinder ----------- Lot Size _ _ C. £.S__-______________ Water Supply: Public System and name -------------------------------------- ----------------------------------------------------------------------Private�]- I Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat❑, Sandy Loam ❑ Clay Loam ❑ E Hardpan ❑ Adobe' Fill Material ."___-___ If yes,type ____________________________ W (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-----4','-. 1__C3_/__ __________________ Liquid Depth --- Capacity _Capacity Type _t�Material__1_. ac -------- ,No. Compartments ---;. ------------- -. l Distance to nearest: Well ------ __-------------------Foundat' s.fQ____________ Prop, Line ___.-Sy_________ LEACHING LINE [ ] No. of Lines --�----------------- Length of each line - - _a_ .Total Length ____ _Q___.______- I 'D' Box Type Filter Material _�� _ �---�_epth Filter Material -----A Distance to nearest: Well ...JZ)_____-___--_-_ Foundation ---/0 ... Property Line. ___ ._-'_�_-___.. i SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C) i Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ ------- Date --------------------.___..______-_) t Septic Tank (Specify Requirements) -----------------------------•------------------ --------------------------------------------------- ------ -- -- -------- -- ------------- 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 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 bec5KAeubject toWorkman's' Compensation laws of California." Signed ---- ------ - ------------- ----------- Owner BY -------------- rsrG - - -- - - ------------------ Title -- +---------------------------- (If o er an owner]`. # f,OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------- DATE . ------ - ------------ BUILDING PERMIT ISSUED - DA'C'E ------- ADDITIONAL COMMENTS _�/ Y__ -u% --. -__ __ �_ -------------- --------------------- ----------------------------------------�`�"� - ��- . ------------------------------------------------------- --------------------------------- ---- -------------------------------------------------------------------------- -------------- ------------------------------------------------------ Final Inspection b ------------------------- ------------------------ --------- ---------------- - -- P Y t r Date --- - - 7 i SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.