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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) Y .. ------------------------------------------ r --- This Permit Expires 1 Year From Date Issued Date Issued K 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 Co my Ordinance No. 549 a d existing Rules and Regulations: JOB ADDRESS/LOCATION ----14=rv------ _---------4)4A7 --:----CENSUS TRACT Owner's Name ._ _ /- D - h_ LG'�s� r ---------------- -------Phone ------------------------------------ -. _ Address ✓ City /f`" •---------- •-•----------- j Contractor's Name --------- aP�_- ----- Q_J.�G.r----------------- ---------License # �/-. _ Phone [�o�__�. ... -- Installation will serve: Residence$Apartment House❑ Commercial [7]Trailer Court i❑ Motel ❑ Other -------------------------------------------- t Number of living units:_______ Number of bedrooms ____f---__Garbage Grinder <_ Lot Size "AAZ- P ---------•-•- ` Water Supply: Public System and name ---------------------------------------- ----------- --------------------•------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam lip— Hardpan ❑ Adobe'❑ Fill Material -----------4 If yes, type ______________________.___ r (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,) J PACKAGE TREATMENT [ ] SEPTIC TANK Size ._ -- _____._.___________- - Liquid Depth ` -------- t _ T e �_ Material-L� �@No. Compartments .ate__._. Capacity -� Type-X.010,_ � �i ----•-- 4 s� i sor Foundation __ �___________ Pro Line _-/fL '.-.-- Distance to nearest: ,Well -----f ________________ _ p• -------- i LEACHING LINE No.of Lines _ __ _________________ Length of"each line--- __ . ._____.-____ Total Length _. ---______....-_ ,�/ 6 ti 'D' Box /1/40- Type Filter Materigl l�,WQ�Depth Filter Material Ar----------------------------- Distance to r)earest: Well __ --_____ ____ Foundation __!`ate+_____________ Property Line. __ZU;�--.----- 4 �, SEEPAGE PIT [ ] D-epthe - ------------------ Diameter --______._ ----- Number ____ _l-------------------- Rock Filled Yes ❑ No 0 I a $; Distance to nearest: Well --------------------- _____y,__' .:.:Foundation ----------_--------- Prop.Water Table Depth Rock.Size ____________________._ Line REPAIR/ADDITION(Prey. Sanitation Permit# ______________________________________ __- Date—-------_------..._________ � SepticTank (Specify Requirements) ---------------------------------- ----------------------------------------------------------------- -----------------•- Disposal Field (Specify Requirements) ----------- ---------------------------------------------------------------------------------------------------- --------------- R -- . . t ! (Draw existing and required addition on reverse side) y 11 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 folllowing: j certify that in the performance of the work for which this permit is is, shall not employ any person in such manner. as to become subject to Workma 's Compensation laws of California." F; Signed --------------�`"----------------------- Owner .« -� # - Title .r.� - 4.----- F B ------------------------------------ Mf 1 (If other than owner) FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY _._W.'--- d------------------------------------------ y' DATE __��Z �.�-------------- BUILDINGPERMIT ISSUED ------ ---------- -------------------------------------------------------------- f-----=------DATE -------------------------- --------------- ADDITIONAL COMMENTS --------------------------------------------------------------------- ---- ----------- `-------------- -------------------------------- ------ r` s ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- J --------------------------------------------------- -- 6 _ _ - _ ____________ Final Inspection b VU : ----------------'-------------.Date . 1 - --�---- - P Y -------- ------------- -- SA{�N JOAQUIN LOCAL HEALTH .DISTRICT F E. H. 9 1-'68 Rev. 5M a