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FOR OFFICE USE: APPLICATION FOWL.SANITATION PERMIT _ ------------„--------------------- (Complete in Triplicate) Permit.No: -------------------- ------------------------------------- -'i •' ;P'ati..� 9-6 Z ________________________---_---_-________________ This Permit Expires 1 Year From Date Issued Date Issued`=— --- 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: L! "`i!_------ -- �- - CENSUS TRACT. -----�-------------- , JOB ADDRESS/LOCATION ._. __ __ �_. Owner's Name .------- of�lr�----{�_ ._ �r �-- ---t--------------------------------------------- ---------- ---------Phone��" Address = _: ./ 7 . -Q ' - 1_� �L.� -----.. City - y i ---- .:. .. _ Phone�_`r Contracto .Name " � ttJ-- License # Tba installation will serve: Residence rApartment House°❑ Commercial ❑Trailer Court •❑ r: Motel ❑ Other ----- -------------------------------------- Number of living units:---- Number of bedrooms•___- Garbage Grinder•_'__ Lot,..Size _-__" ------- Water Supply: Public Systemci cd name ___________________________ Character of soil to a depth of 3 feet: Sand'❑ Silt.❑ Clay EJPeat❑ "Sandy loam ❑ Clay Loam [ ... , ..: , Hardpan ❑ Adobe ❑ Fill Material __f- __._ If yes,type __ _.______._______---- {Plot plan, showing size of lot, location of system f 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 -F__-_,------------------- 1 � ,`.�11^ D stance to nearest: Wel'____________ ___�___€________•_____.Foundation - No. Compar#menfs€ -_____.."__._..._.__.. Type -------------------- Material °a ine Prop. L' LEACHING LINE [ ]�,t�No.z of Lines---_--------------------- Length of each line---------------------_----__-Total Length ___ _.._...". .__...__ iA 3'D' >Box ------------ Type;.Fil.ter Material --------------------Depth Filter Material ------------------------------------ --- Distance to nearest: Well ______________________7 Foundation -------_---------------- Property Line ------------------------ Depth SEEPAGE PIT ". [ ] p -------------------- Diameter ---------------- Number :,_:-; --------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------'` Rook Size _ ,. Distance to nearest: Well ---------------------------------- -----Foundation _._ --- ------------ Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit#--------------------------------- --- Date --{J� -------- Septic Tank (Specify Requirements) _______________________ - Dis; posal Field (Specify Requirements) --- �_---- . __uQ__-- -- h ` = = I'----------_-em- d-- ----------- ----------- t _ off.- T` ` ------------------------------------------------------------ ---------------------------------- --- ------ (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. Homeowner 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 ---------------------- - ----------- -- ---------------------------------------- Owner BY --- ------------ ------------- ------- Title --- T------------------ ; ------------------------------- 20/ r than owner) ' FOR DEPARTMENT USE ONLY 1 APPLICATION. ACCEPTED BY _-K-__®----------------------------------------------------- ----- DATE --- BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------- ------ --- ---DATE ------------------------------------------- ADDITIONALCOMMENTS -- ---- --------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- ------ --------------- ------------------------ ---------------------------------------------------------------- ---- ----------------------------------- ---- - --------------- -- } - - - Final s ection b - -------------------------- -------- .Date __.. f - �- ----------- t SAN JOAQUIN LOCAL HEALTH DISTRICT a E. H. 9' 1-'68 Rev. 5M