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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 1p�0 Permit No. �---"--------•--- -- -------------------- --------- ------------------- -- (Complete in Triplicate) -------------------- 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 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ------ ��-7 -- ------- ,/ s�- --------- ------------------ CENSUS TRACT - -�:7------ Owner's Name ------- -- ------- ------ -- - - ----------------------------- ----------- -- Phone ------ ------- = = -------- Cit -- --- ---- ------------------------------------------------- Address - a /� " -------------------------- Y Ph er - one -------------------- --------- Contra -- --- -- ---- ctor's --------Contractor's Name --.___.--- ------_ License # Installation will serve: Residence [Apartment House❑ Commerxcia�❑Trailer Court ,❑ Motel ❑Other ---------------------------- ='--------' "- Number of living units-----/------ Number of bedrooms - --------.Garbage Grinder --_____.___ Lot Size __ �'----------- Water Supply: Public System and name ----------------------•--------=1-------------- ----------'--- .................. --------------------------Prrvat e Character of soil to a depth of 3 feet: Sand F1 Silt❑ _s Clay-El Peat[j ;'Sandy Loam ❑ Clay Lbam El Hardpan X Adobe ❑ , Fill 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.) R} NEW INSTALLATION: (No septic tank or see age pit permitted. if public sewer is available within 200 feet) PACKAGE TREATMENT ( ] SEPTIC TANK'[' Size_ /%�'-x�'----- - fir- f Liquid Depth ___. Capacity -1._ _bQ"r(`} Type ,Material--- � s'- 'No. Compartments .;, -._'_.. '. Distance to nearest: Well ----_------ '------- -.4=------Foundation ,--- a--- ---.---- Prop. Line :__..S_y__•----;.-- No. of Lines _" Length of each line____._/ Q_�_._""__-- Total Length _pe?-0Z- --------------- LEACHING LINE [� --- g Ej Yenal :'`�' Depth Filter Material ��' •---•-- S D' Box -_- _.__-- Type Filter----p°-�---- ="-- Foundation - Property - - YP Distance to nearest: Well 1 d" Pro er Line. o7-` _ Rock' Filled Yes -01" No SEEPAGE PIT [d Depth ------ --5- ----- Diameter -----✓ ------ Number ---------------- Water Table Depth -------I_P4-- --..il ------------------- •----Rock Size.--1 'x 3 Distance to nearest: Well ------------f 0"-4-------- ------;.Foundation 1-a+"`--------- Prop. Line ------•-'---- REPAIRJADDITION(Prev. Sanitation Permit# ----------------------------------------------------------------------- Date ------------------------------------ Septic --------------- -;•------------Septic Tank (Specify Requirements) ----------------------- - ----------------------------------- - ----------- Disposal Field (Specify 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 San Jaaquis County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hosie owner or ficen- 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 __. n -------- ------- Owner ------ - ------ "n""r'��{ d Title �c -f' - = BY -------- ------------------------ (If other than ownerl / ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _- - - ---------- --- ---------------------------- --- - DATE "�_ �j ------------- BUILDING PERMIT ISSUED = = ---------- ----DATE ""----------- ---------- ----------------- ----------------------- ADDITIONAL COMMENTS ------ -- - - ---------------------------------------- ------------------- g `�'' `� - '/�=_ Y -------_----------------- ------------------ -------------------- - - ---- -- ----- - - t a - -------- ----------- ----- - - _ _ -------Date -- ----- - �� -� ---�-- ----------------- Final Inspection by: SAN JOAQUIN LOCAL HEALTH•-DISTRICT- - - -- , - E. H. 9 1-'68 Rev. SM