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:FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i Permit No. __�L�yl6------ -------------- -- ---- ------ - +' (Complete in Triplicate) ______________________________ __. ' Date Issued .S`" .71.--• 1 ` This Permit Expires 1 Year From Date Issue ; ' - Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein pP y describetl:rThis application is made in compliance with County Ordinance No. 549 and existing Ru and Regulations.,� w , . ------CENSUS I ]� CENSUSTRACT _ _ » JOB DDRESS/LOCAO -.. --- *= ---- - --- ----- ----_ � Owners s .-Name �l ------- �- _ _ _- -------- V -- -- rj I ' k,t f �j r Q��`s arm • jam_, �_.� a :�� k I Addr ssiG?��f� -�7 ,� a _ Phone ' � ,� ---.License # -- - �-.� ----- -- Contractor's Nam - ` ice-°1 4 `mss I 'J ResidenceXXpartment House'❑ Commercial ❑Trailer Court ;❑ Installation'wil'l,serve: ; j � Motel ❑Other - Number of living units:---_ -- --- Number of bedrooms�-----Garbage Grinder -_____-_.__ Lot Size ---.___-------"--------- Private Water Supply: Public System and.name _________I----------------- peat Sandy Loa Clay Loam ❑ i Character of soil to a depth of 3 feet: Sand' 3 Silt❑ - Clay ❑ ❑ / ` I iHardpan ❑ j Adobe E] Fill Material If Yes,type -- Plot' tan, showing size of lot, location of system in relation to wells.,_buildin.gs, etc -must be placed on reverse side.) _ ( p r I s i +t erm+tted if public sewer is available within 200 feet,) ., .. � r NEW.INSTALLATION: (No septic tank or seepage p p Liquid Depth ,.__".__________.___,____ SEPTIC TANK'[ ) Size--------------- ---------------- i x PACKAGE TREATMENT { ] l t No. compartments Capacity Type Material- p pY -------------- -- Pro Line ------ -----'-------- 4 �� Distanced to nearest: �Weli ___________________ -----------------Foundation p I ----- Total Length ..--------- H1NG LINE [ No. of Lines ----------------------- Yp _ Length of each line----------------- ; •. Depth Filter Material --------------•-- ---.�-----•-=----� y-- t 'D' Box --------- -- 7 -_e Filter Material . ;_:_, P a �.. — • - - ------- LEACHING - _ - _. ..��_ - -- - -- Property.f Line -------- Distance - -- T r • -,,. .r. - Foundation ---------------- . _ Distance to nearest: Well _____-__.__. -- " -- - . f •* � `N k t * --_____ Rock Filli d-�;Yes ❑ o '❑ i t Depth t ) Number ----- ------ - -- Diameter -------s-------- I SEEPAGE P17 [ ].� p -- --- - ------ - ' E Water Table Depth ------' '----------- Rock Size - J'1 t Foundation -------------------- P Distancerop. Line I +to nearest: Well ----- REPAIR/ADDITION(Prev. Sanitation Permit# _f------ ---------------- Date ----------------------------------1 � Septic Tank (specify Requirements) ------------- ------- _ ' ------ r----- Disposal Field (Specify Requirements) ---- ------• ) t v t ------------ - ----------- ----- //T��/(T){.+.� ----------------------------- ' (Draw existing and required addition on reverse a+de) r•� l l hereby certify that 1 have prepared this application and that the work will be done an accordance with San Joaquin Joaquin Local-Health District. Home owner or County Ordinances, State Laws; and Rules and Regulations of the San licen- sed agents signature certifies the following: i -erson-in-such manner "I certify that in the performance of the work for which this permit is issued, I shall not employ-any-p as to'bccorne subject to Workman's Compensatlo1 0 laws of California." `' F } Owner + Signe ----- --------------- - • , ) ... Title BY r (lf other than owner) ; 1 �F R EPARTMENT USE ONLY .r DATE _ =�� !/ --------------- - - - APPLICATION ACCEPTED BY .___"- --- -- - ------- BUILDING PERMIT ISSUED __--'i--------------------- ------- ------------------ ------------ ADDITIONAL COMMENTS `- ---------- ----------------------------------------------- -- ----- ---- ------- - --------------- - - _n ` t �._.------. - - _ ----- . ------ ---- -- ---------�--�- _ _ Date _--_: ------------------------------------- - - - --- -------- - i Final Inspection by:`� SAN JOAQUIN LOCAL HEALTH DISTRICT � I r � F. H. 9' R 1-'68 Rev. 5M