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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - ----------------- fD,'3-d--------- M ,.. -� Permit No. - -----� (Complete in Triplicate)11. 6e)--------- ------- ----- -- --- ----- ------ Date Issued �_-�.------ • .t 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 --- __ --- --- ----- --- CENSUS TRACT -------------------------- Owner's Name ----X11—V ------ ------------------------------------------------------------ ----------- --Phone .--------------------------------• -- ----- ------ -- --- -- ,�-a- ----------------------------------------------------—. City -- Contractor's Name -----. /L -'� ��------------- ----=--------License #`�� - .- Phonet•��► � --- Installation will serve. Residence Apartment House,❑ Commercial :❑Trailer Court i❑ // Motel 17 Other ------------------------------=------------- Number of living units:...!_----- Number of bedrooms --a�-_--Garbage Grinder -�AO. Lot Size -.��-'e— ------•-------- rup Water Supply: Public System and name ----------------- ------ ---------------- ---------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ,[I Clay Loam .0 Hardpan ❑ Adobe � 1;14C7-Fill Material 1;14C7- _ - If yes,type -------------- -.- -------- ? (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 4 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------- ----- - Liquid Depth -------------------------- No. CompartmentsCa Capacity ----- ------ > - Type -------------------- Material----- --------------- --------- - Dis,.tance -t.onea'rest: Well ------------------------------------Foundation --------------- --- -- Prop. Line -----------------=- ••-- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------.------ Total Length -------------------.-------- � 'DS Box ------------ Type Filter Material--------------------Depth Filter Material ------- ---------------------------- ------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line --------.--------.------ SEEPAGE PIT Depth Diameter ---------------- Number --___.-.------------------- Rock Filled Yes ❑ No 0 Water Table Depth --------------- -_Rock Size -------------------------------- �t Distance to nearest: Well -----------------------------------------Foundation --:----------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------- - Date -------------------- ------------- r Septic Tank (Specify Requirements) --------'---------- -- - t! r / I Disposal Field (Specify Requirements) P.� d r f------=----- ---- ----. ------------ --------------------------------------------------------------------- (Draw existing and required addition on reverse side) F. 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 licen- sed agents signature certifies the following. Y` "I certify that in,the performance of the work for,whieh this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Con pensatiAn laws of California." t signed -------- - # 3 Owner -- -------------------------- ------ - -y------ ------------- -- -- Z. e T i (if othe than own t s EPAitTMENT USE ONLY N -------- ----------------- --------. DATE Zyr r-------------- APPLICATION ACCEPTED BY ------------= -� - -- - ----------------- t - BUILDING PERMIT ISSUED ------------ -- - -- -------- ------------------------- ---------DATE --- --------------------------------------- ------------------------------------------------- ADDITIONAL COMMENTS � -- --- -- -- ---------------------- ----------------- ----------- �67�� 5 ---------------------------------------------------------------------------------------- ------ ------ f I. ---------- ------------------------------------------------------ ------------------------- Final Inspection bY ----------------------- Date /}� - ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ,�