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€ FOR OFFICE USE: . u�-o APPLICATION FOR SANITATION PERMIT -•---- •- ... .... Zr. (Complete in Triplicate) Permit ..........I........ . .............................. . 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 isting Rules and Regulations: JOB ADDRESS/LOCAT --------------t .................... ':�_i�--._._h, 1--ze/:7°_ _ -��CENSUS TRACT ... j .......... ... Owner's Name ... p� . •...............................•-•--•..--•---.......---------.... Phone .. ------ --•--------•--...._.... Address ..........16--{Q�� --�---- - - ------ --------------------- City •=--- �-------- -----------[---�------------.._.._.__. Contractor's Name ........... ... ! .------ ...................::--------License # ��✓c?�$Z Phone ? Installation will serve: Residence❑Apartment Housef] Commercial❑Trailer Court ;❑ I E Motel ❑Other-On ...... Number of living units:..._2.—Number of bedr'oorris ..... ......Garbage Grinder a_.. Lot Size ................................ ........... Water Supply: Public System and name ............................. .....................................................-........................Private,' Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loom •❑ Clay Loam D Hardpan ❑ AdobeFill 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,l i PACKAGE TREATMENT ;. J SEPTIC TANK[ ] Size..............................................-- Liquid Depth.------_------•--_---,-•.-- Capacity ------------ ....... Type .................... Material...................... No. Compartments ------•-----------•-- Distance to nearest: Well ....................................Foundation ................. Prop. Line...................... LEACHING LINE [ ] No. of Lines ........................ Length of each line................------------ Total Length ; 'D' Box ............ Type Filter Material ...................Depth Filter Material ..........................t Distance to nearest: Well ........................ Foundation ..._..._ ............... Property Line. __......................f . SEEPAGE PIT [ ] Depth .................... Diameter .--------------- Number ..._.._._...._.._.._....... Rock Filled Yes ❑ No 0 Water Table Depth ................................................Rock Size ..........__....---. ............ Distance to nearest: Well _..•....................................Foundation .... ............... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit _______________________ Date __ -__•--___-_--._---_._-•-- ,t - .... ti Septic Tank (Specify Requirements) .............. :. d �. Disposal Field (Spec ify 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 Sola Joaquin County Ordinances, State Laws, andRules and Regulations of the San Joaquin Local Health District. Homeowner or licen- sed agents signature certifies the fallowing: "I certify that in the performance.of the work foi•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 ------------ --- --•---.....------ ..............-•---•-- -other than owner) ARTMENT .USE-ONLY APPLICATION ACCEPTED'BY__.... . ... ...... .............................................!-...._... DATE .... 'T•�5 ul -------- BUILDING PERMIT ISSUED .......... ... --.__DATE....-......................-•-:---•----.--. ADDITIONAL COMMENTS...... ..............•.........•.....-.......................... ................................ . . ....... . -- • .....................................................-•-................................... ............ . .................................. .................. ......................... ................................ Final Inspection by: ------ :- - !y-.. •••--•................Date ._... -.•, �j•._. ..._ ; ; N JQUIN LOCAL HEALTH DISTRICT. 'k E:H. 9 1-'68 SM �;