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FOR OFFICE USE: �- 16 qve- APPLICATIN FOR SANITATION PERMIT Permit No.—1' -�----- 1 --------;----- ----'`�------- ------------------ - ----973 (Complete in Triplicate) ----- --------------------------------- Date Issued .�,�--o 47 = This Permit Expires 1 Year From Da te Issued iv 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: ---.CENSUS TRACT .---------- - JOB ADDRESS/LOCATION <------- ._ -O`�O n(�tJL�y- r. a - Phone Owner's ' Name ------- ------ "Y ---- -- City ---------- Address � ------------------------------------------------------------ Contractor's Name --------- IULp ------------------------------------- --=--------License #-------------------------- Phone ------------------•-------•--- Installation will serve: Residence (Apartment House^❑ Commercial :❑Trailer Court 0 Motel ❑ Other -------7------------------------------------ 7 Number of living units:-------/--- Number of bedrooms --__ ...Garbage Grinder ------__-Lot Size -�al- ` ................. Water Supply: Public System and name .................. ...... Private NR Character of soil to a depth of 3 feet: Sand Silto Clay ❑ Peat E] Sandy_Loam '❑ Clay Loam.❑� Hardpan ❑�" Adobe❑Fill Matarial�.__...- 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-------------------------------------- - Liquid .Depth -------------------------- Capacity -------------------------Ca aci t Type -------------------- Material---------------------- No. Compartments ------------ --------- D;stance oto nearest: Well ------------------------------------Foundation --------------------__ prop. Line ----------.----------- O [ LEACHING LINE [ ] No. of Lines --------=- ------------ Length of each line.--------------------------- Total Length ------.---------_--------- 'D' Box - ---------- Type Filter Material --------------------Depth Filter Material -------------.---------------... - hiiii i Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ----------•-------•=--•- SEEPAGE PIT Depth - - Diameter ---------------- Number --------------- ------------ Rock Filled Yes ❑ No Water Table Depth ----------- ------------------------ ----- -Rock Size -------------------------------- I Prop. Line i Distance to nearest: Well ._ ..._._-._..........................Foundation p• REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- Septic Tank (Specify Requiremet nts) ........................ .... -- --------------- •'-- D'+sposal Field (Specify Requiremen ts)-------------------------------------------- ------- F ----------- -- --------.................... 1 __ _ ..............r---_...._.._.-._._._..__- ._..... .............-------------------------------: ............................... 3• 4 - Y ................... . _ J .._-_ ..._.- - -. (Draw existing-and required addition on-edverse sidel I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State taws, 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 be a bi o Work 's o pensation la of California." Signed --- -- --- Owner --- -- -------------- - ----- ----------------------- T O itle / -- --------- T -- � ��(�� (If other an owner) t 01? 4, g C OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY , I --.`=---------------------- ------ DATE ��t :. --- ----------------F-----T------�------------------- ---- --- BUILDING PERMIT ISSUED ---------------------- - --- DATE ADDITIONAL COMMENTS -------- --------------------- ------- ------- - ------- ------------------------------------------------------------------------------------------ -- k ------- ------------------ --- -------------------------- f ----- `--- ---------- ----------------- --------------=---------------------------------- ----- Final Inspection b -------.Date ------ --------------------------------- --- ], P Y ----------- --------------------- g SAN JOAQUIN LOCAL HEALTH DISTRICT i _ yN '8M H. 9 '", 1 '68 Rev. Y y -. _