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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Pe _ (Complete in Triplicate} = rm it No. ------ ------- --------------------- --------- 71 __ This Permit Expires 1 Year From Date Issued 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 mad6 in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION;_b!l4_� _ _�_ -_ f, d�t.._ CENSUS TRACT s y D ----------- Owner's Name c ' -------------------------=--- --- �v�,, t- - ----- ------Phone ----------------- Address - ---- -------Address t� ��- i e d4� .. ------------------------------------- City - — ------------------------------------------ ------ Contractor's Name ------------------- License # fs� 3d' Phone Installation will serve: ' Residence ❑ Apartment House❑ Commercial ❑Trailer Court. ;❑ I Motel ❑ Other -------- Number of living units:__._.. Number of bedroom s3Garbage Grinder ------------ Lot Size ------------__________ i Water Supply: Public System and name --------------------------------------------------------------------- -------------------------------•--------.Private ❑ k Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay [I- 'Peat❑ Sandy Loam .lj�/ Cla'y Loam ❑ Hardpan ❑ Adobe ❑ Fill Material _.___..-.--- If yes, type ___-._----_'._____________ 1 - (Plot plan, showing size of lot, locatiori'of:sys6rn'in r6lation to Wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: JNo septic tank'or-s66page pit permitted if public sewer is available within 200 feet,) T/ PACKAGE TREATMENT [ ] SEPTIC TANK'[ 4 Size_�{,1:1 �_ ,Y.�---------------------- Liquid Depth ---V---------_--------- �p CapacityI')_Co_ 4.k -T e "".�"` ` yp Material No. Compartments __�_____X.A—C41" Distdnce to nearest: We"II ---- - -�----- ---- -----Foundation ---------- Prop. Line -__5------_----- LEACHING --- -----LEACHING LINE [ I No. of Lines ---.Y-------.-------- -- Length th of each line----$_�F__----------------- Total Length ___3?�a------•---_-_-- 'D' Box Type-Filter Matenai ---!R---------Depth Filter_Material --------10_____-______________._..--_-•_ Distance to-'naaresMVVeH----4 �--yh------ Foundation ` l p ---------- Property Line ' [ l Depth I :t. ° ' t; --- --- teeter 2__-n--1Q---- Number ------J----------- ------- Rock Filled Yes ff' No 0 Water Table Depth„_---- -a?4S-f......--- Rock Size r f� ��'C--.3 r� a �p / - - Distance to nearest: Well ----------------Foundation ---Ip_r--------- Pro Line ---�-----......... REPAIR/ADDITION(Prev. SanitationPermit# -------•'-------- -------------- Date ------------- -------------------- -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 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: i "I certify that in the performance of the work for which this permit is issued, I shall not employ any person. in such manner 1 as to become subject to Workman's Compensation laws of California." Signed - ------------------ ---------- Owner BY ' ------ Title (if other than owner) 9 FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY :____ _ _ - - l DATE --- .y BILDING PERMIT ISSUED -- ------------------------------------------------------ -------------------------- --- --------------DATE ----------- -------------------- F ADDITIONAL COMMENTS -------------- --------- -------------------------------------------------------------------------------------------------- ----------- ---------------------- _ __ --------- - ---------------r/- ----- •-�- - - ---------- Final Inspection by: -- --------- ---------l�` -P. -------------------------------------Dated<, - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M '