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r ' FOR OFFICE tJSE: " APPLICATION FOR SANITATION PERMIT ----------`------ -• Permit N� �_6-� .. (Complete in Triplicate) y ' ' Y --------------------------------------------------------- --------------------------------------------------------- This permit Expires 1 Year From Date Issued Date Issued S��-7s� 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: t JOB ADDRESS/LOCATION ._tTI S ` -' ------------------ ----------------------------------- -----------------------CENSUS TRACT -------------- Owner's ------------Owner's Name L► � 1 Phone 05' 6371 Address ------------------------------ ----- ------------ Cit-- -- - - -_-Licehse #ZW Contractor's Name i 3 Phone ------J��-7_.._ Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court 0 Motel 6 Othe------------------------ _ _. ��- Number of living units:_._._____ Number of bedrooms__ �Garbdge Grinder - Lot.Size ---- Number �_______.________ Y --------------------------i ��-- ---------------- efl ---------------Private ❑ 1 i Water Supply: Publics stem and nam ---- ---------------------- Character of so!I to a depth of:3 feet. Sand [] Silt']] Clay ri,).rPedt❑ Sandy Loa ❑ Clay Loam,D �J Hardpan.❑ Adobe Fill�Materia! ______.f Al f yes,type ____________________________ k (Plot plan, showing size of lot, location of system in relation to w.el•Is7'bu(dings, etc. must be placed on reverse side.) (. NEW INSTALLATION: (No septic flank or a pages p mitted if public sewer is available within 200 f6et,) { ] SEPTIC TANK; ] Size____________ 1 q p ' PACKAGE TREATMENT ( � � ---- Liquid Depth --------------------------- I __-________ / I Capacity -'-�-------- ---- Type -------------------- Material---------------------- No. Compartments ------•------ VDistance' totriearest: Well _______________---------------------Foundation - ----- __-___---___ Prop. Line .-..___ -------------- LEACHING LINE [ ] No. of LinesAr____ -_.]- ------_- - Length of each line________________ sI - Total Length ------------------- -------- 'D' Box ____ --.-,"Type' Filter Material ____________________Depth Filt dr Material --------------------.________•---- ..-___ Distance to, nearest:�Well�___________—�_=_—�F.oundation---________I___._________ Property Line ------------------------ t SEEPAGE PIT [ ] Depth! ______ ---------- Diameter ________________ Number -------- ------ ........r.__ Rock Filled Yes ❑ No 0 Water Table Depth --------------------------.------- -------Rock Size _1----------------------------- 7 Distance tolnearest: Well _---_.- �' �. '' ____-____-Foundation_._____--.___--____-_ Prop. Line ____________ ________ ----------- i I Y 4 1 REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ___________ ______: __---..____) Septic Tank (Specify Requirements) ________._ -,-. - ---------- ------------------ ----- ir Disposal Field (Specify Requirements) ----------- - ------------------------ ----------------- ------------- ---------------- ---------- -------------- --------------------------------------- -------- ------------ - ------------•------------------------- --------------- --------------------------------------------------------------------------- ------------------------------------------ .�.._(Draw_existin,g 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 Compensation laws of California." Signed ----------- ------- ------I---�-----A , ---------------- ------- Owner ------------------------ BY --------------- Title - (if other than owner) i f t) FORJDEPARTMENT USE ONLY APPLICATION ACCEPTED BY i-- j 4 -------- -------- ES '�� ------•--- �./fit BUILDING PERMIT ISSUED --------- 4! / J___ ATTE _---------1 ------ - ADDITIONAL COMMENTS --#------- --- ---- - - f �C ' _ ---------------------- -------------------------------- - ------------------- --------- - ------------ -�-- -------- ------ ------ -------- ---- -- ------- u �4° — Final Inspection by: ----- ------ -------- -------- ----------------------� D e _ =-_�------------- SAN JOA IN LOCA17HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M