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tel. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: _.7 '_V ------ ---- -• - ------------------ 4 --- - t } (Complete in Triplicate ---- --------• p Date Issued This Permit Expires 1 Year From Date Issued 3 -0� ------------- - zt3 work rict for a mit to and Application is hereby made isomade-in compliance with CounttytOrdinance No. 549 and ex sti g RulestalndthRegulationsrein dgscribed. This.appllcat a- CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION __--- -- --- �D Phone r `" -- - _� Owner's Na e�01�1 - (��-- ----1 ��SB�---- - �S°------- --�----- ----,,- -- .» � _._.. City lV�f1✓�I�fi�------ -------- ----- - - - Address ';)1-6--?- ---N---ice-Irk------- _ --------------------- �7 .._ .._. t� +✓�1_ License #o� �• �d--- -- Phone ""----- Contractor's Name ___-__-�� --t Installation will serve: Residence [] Apartment House,N Commercial ❑Trailer Court V Motel ❑Other --------------------------------------------- Number of living units:------------ Number of bedrooms _______-__-Garbage Grinder ------------ Lot Size _._ _______-___-- ----•------ ---""--- Private Water Supply: Public System and name _____________________________ # Character of sail to a depth of 3 feet: Sand❑ Silt ElClay ❑ Peat❑ Sandy Loam ❑ Clay Loam EJ Hardpan ❑ Adobe'❑ 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.) y NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feetA PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------- �- !Q_ ------ Liquid Depth _/?/- ----------------- (31 Od C� 7Rateriai_ _ No. Compartments _. ------•------•--- Capacity _ ------ Type ��'t"� Distance to nearest: Well --- ----------------- Foundation _ - r---------- Prop. Line _ ------------•C' , No, of Lines ____ Length of each line. ------ ___ Total Length -------•------ h LEACHING LINE [ , 1 w'D' Box .--_-• =-Type .Filter Material _l��e ---Depth .Filter .Material./ _----_---_---•- .ri ______ Foundation ------------------------/8 rProperty-Line 167-11 i Distance to nearest: Well _._ �iC3--- De th ' Diameter Number ------------ -------- Rock Filled Yes C] No �] SEEPAGE PIT [ } pxi --- -----ixR Water Table Depth __ ock Size I ----------- Distance to nearest: Well ------.__,-------------= - ---------Foundation ---------------•---- Prop. Line _•------------------ - REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ----------------------------------1 � q I _ ------ - ------------- --------...- ------- Septic Tank (Specify Requirements) ---------------------------------------------------•`-----; x ----------------------------------------- Disposal Field (Specify Requirements) ---------------------------------------------------------- l -------- ---------•----- ----------------- - ----- --- --------------------------- (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 will► San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Nome owner or licen- sed agents signature certifies the following: t" "I certify that in the performance of the work for which this permit is s;ued, I shall.not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ____.--_-`_- Owner ----------------------------- 7itle _ ----------------------------------------- By ---------------------------------- ----- BY r J other than owner) FOR DEPART ENT U ONLY , APPLICATION ACCEPTED BY ------------------------------------ , - - --. - -- ---- y�'---------� DATE -----�'�-�,-�L-- --------•---•--• ------ -, � ---- ------DATE _._ --------•------------------ ---•---•-- BUILDING PERMIT ISSUED ------------------------ ------ --- -----" -- ----------- ADDITIONALCOMMENTS ----------------------------------- - -------------------------------- ----I--------------------- = ----- --------------------------------------- - --------------------------- - --- -------------------- Q�7 :-- ---------------------------- _ --------Date --- �-- -- - Final Inspection b """ ------------- - - --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT _ ±� IN- E. .E. H. 9 1-'68 Rev:`SM