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FOR OFFICE USE: ---------------------------------------------------- APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ..........I---------------------------------------------- 0 Date Issued ------------------_-------------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descri ed. This op iication is made in cq fiance with County Ordinance No. 549 a Rules and Regulations: JOB ADDRESS/LOCAT N --------"---- -- ------ ' =--------------CENSUS TRACT -------------------------- Owner's Nam � ANG '�' .........-""-----Phone e�K.7t�� r Address ---------- ----: City __-(I `-`-V ------------- - ---•---- Contractor's Name ___- -: _ _ -- --� =---- ------.License # > t. _ Phone �"nz .!- ` Installation will serve: Residence 'Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other ------------------------------------------- Number of living units:---. .___--- Number of bedrooms _��'__ ------Garbage Grinder ._-- Lot Size Water Supply: Public System and name --------;—A ----------- -_ 4--------••-----•----------------•--•------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt o Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan.[]--Adobe Fill Material ___________ If yes,type ____________________________ y (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK [' Size-_Is-- _�rr-----,X__. `:7------------ Liquid Depth ---_ 7- -_______-- Capacity�c4___&VType ;_0/14 Material____ _: No. Compartments _.__ ....... - Distance to nearest: Well ---- --------------------Foundation __ ____________ Prop. Line -_--_ ..:..._____ I , 9 s �- r LEACHING LINE No. of Lines - e Filter Length of each line__ ...<T _____________ Total Length 'D' Box Type Material ___.,rke,14�._Depth Filter Material ------/V-------........................ it Distance to nearest: Well � ___� Foundation — -r-.--.----- Property Line ------- SEEPAGE PIT [ Depth _ '�f______ Diameter _-� `�-- Number ------a----------------- Rock Filled Yes, No a Water Table Depth ---------5�r-j--------•------------------Rock Size -------rZ-----.--------------- 1 - --rte--, Prop. Line --�_-.e..... Distance to nearest: Well .�'�:_..___r_�_ ___________________Foundation --- REPAIR/ADDITION(Prevk.-Sanitation-Permit# -------- ----------------------------------- Date ----------------------------- Septic Tank (Specify - s Requirements) ---------------------------------------------------------------------------------•---------------------------- ------ Dis,osal Field {Specify Requirements) ----------------- -------------•---------------------------------------------- -------------------------------------- --------------p s ------------------------------T--------------------------------------------------------------------------------------------------------------------------------------------------------------- 1"" �:._ _ = ---------------- ------------------------------------------------------------------------------------ ----------------------=----------------------------------------------------------------------------- 1 {Draw existing and required addition on reverse side) I hereby certifyithai 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- t sZ 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 -- ------------ s - ------ Owner .. By ---------------------------------- Title -- -------------------- --- --- --- ---- -------------- (If other than owner) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY;-- r --------------------------- -------------------------------------------------- DATE __4-� 1_7. PERMIT ISSUED -------------------------------------------------------------------------- ----------------- ----_-------DATE-_.__�------------------------------- ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------- -------------------------------------------------- -- -- '------------------------ --------------------- ------- ---- - - ------- ----- = ------------------------------------ --------- ------------- - ---------- -------------- -- Final Inspection by. - = Date SAN JOAQUIN LOCAL HEALTH DISTRICT r f E. H. 9 1-'68 Rev. 5M