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Y" FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -- ----- -----------------�-- -------- --------- 1 Permit No. -- -----r----'--7 (Complete in Triplicate) ------------------- -------------------------- ~/ 3 Date Issued -....__...... .-- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District fortia '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: JOB ADDRESS/LOCATION � .- --- : 1 - -Cp% 15".r------------------------•i---CENSUS TRACT --- ---------------------- ,e ----------------------Phone ------------------------------------ Owner s Name --- Address ---------- �---`--�------ -------------- ---------------•--. City Contractor's Name --------- �_l/--.� #� . 1� Phon -r -------------------License e '1 '�r' ---- Installation will serve: Residence E partment House❑ Commercial :❑Trailer Court i❑,x t Motel ❑ Other _ Number of living units:-.--- --- Number of bedrooms ___0'Garbage Grinder . I ' rot Size _'. ®---- Water Supply: Public System and name ------- - -------------- ; ----------Private ❑ Character of soil to a depth of 3 feet-._Sand❑ Silt❑ ,,,,Clay❑ Peat❑ Sandy loam ❑ " Clay Loam -Hardpan ❑ ,�Aclbbe Fill Material ------------ if yes type ------,t------------------ (Plotplan, showing size of plot, 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,),. Q PACKAGE TREATMENT[ ] 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 _Depth Filter Material 'D' Box --�'--- ---�T 4 e F•-ilter,Material------------ ------ ---------------- - -----------------••------ k""""� �`` Foundation '------- --------- Property Line Distance to nearest:'Well .__ __ ------ I< WaterTable Depth ---------------------------------------=--------R'ck Size -----------`-------------------- t -_ Pro Distance to nearest: Well ---- -- --------------------------------Foundation _.__�-----._..-- p. Line -----•----------__-.-- REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------- -------------- Date ------------ --------------------1 Septic Tank (Specify Requirements) ---------------- --- ------------------------- ------------- Disposal Field (Specify Requirements) __-- --, _. �� - ---- -- : ,� -- �-T'` ' l --------------- - - - ?'y 3 ---------------------------- I ! (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. Home owner or lieen- sedfagents 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 ompensation laws of California." LLSign_ed: 4 -- ----------- ---------------------------------------------- Owner / ByF -----------------------------------------------------VTitle ---1e5)r4 .% -------------------------------------------- than - - -- - ------------------------------ If other than owner) FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY -- ^ --------------------- DATE _.C//J-7l.[----_-df---------------------- BUILDINGPERMIT ISSUED --------------------------------------------------------------------------------------- -----------------DATE ----------'--- ----------------------------- ADDITIONAL COMMENTS ---------r-47 Z- ----------------------------------------------------------------------------------------- ----------•--- ------------ l --------- ---- --------------------------------------------------- ------ --- -------- -------------------------------- : ----------------------------------------------------- - Date Final Inspection by _ L - ( SAN JOAQUIN LOCAL, HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M