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FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT {Complete in Triplicate} This Permit Expires 1 Year From Date Issued n . Permit No. Date Issued, 4--64A. Application-it•h6rehy-iila'de-ta-the'Sdn 'Jaaquin-total-He-alth-District fora--permit~to- construct and- install -the work herein described. This application is mdde\in(,compliance';w.ith'Cdunty,,Ord inance No. 549 and existing Rules and Regulations: ----CENSUS- TRACT ��-~: f-�- ------ JOB'ADDRESS%LOCATION----__-- 4,�---- ---� % 1� - dA*; >i C�? WO--------------- ----- - - Phone Owner's Name -: - City,_%321+�fL�'Ka¢---------------------------------------------- Address ' ' .fel , fi>>� r �f_;------------------- ----- -- / Contractor's Name __D--Z---------0,4/---V_ / ` --------------•--- --------------.License #4 e �/K_ Phone Lnstallation will serve: Residence Apartment Housea❑-Commercial ❑Trailer Court f T - - — Motel ❑ Other— �/� Number of living units_____________ Number of bedrooms _______Garbage Grinder _---_-----_ Lot Size 4cm--e----------- Water Supply: Public System and name _-___________ ------Private Character of soil to a depth of 3 feet: Sand'❑ Silt ❑ Clay .❑ Peat ❑ Sandy Loam'Cldy Loam Hardpan ❑ Adobe F7.1Fill Material If ryes, type -________________--______ (Plot plan, showing size of lot, location of system in relati n to wells, buildings, etc. must NEW INSTALLATION: {No septic tank or seepage pit .perms ed if pulic sewer is available w PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] S e___ _. -_ _t`�._)_y -a --- -- L Capacity _�_o�`V�f -- Type Material_rfNo, I Distanceto nearest {Well _'_'':'_-f----------------Foundation LEACHING -CINE [ ] No. of Lines ___` _ - I rrgt bf each line----------- ---------------- To - 'D' Box ------------ Type Filter Material ��-----------_Depth Filter Materia D' placed on reverse side.)` ii 200 feet,) ` ;uid Depth -- -.-------,----• a �rnpartments -,_ Prop. Line --- 1 Leith -------- �- Foundation __�_� ro `er ' Line __------- .-; Distance to nearest: Well ____`5 -- _-_-_ ---� ------ P t7! SEEPAGE,P�IT [ ] Depth ___ Diameter , _ -____ R ck' Fill'ed Yes No Number ❑ ❑ Distance to nearest: Well ____________ _ Foundation _----_- Water Table Depth - -- = --------------------Rock Size ------------------ --------- r 'Prop. Line REPAIR/AD DITION (Prev. Sanitation Permit#}�__________--------' ----------- Date �----t---!-----r-,'� -;.-S- ------- N I- -_ Septic Tank {Specify Requirements} --------- ` } f --------------- ----- — -- -----•---�---- -_-- sposa Field (Specify Requirements) � X ------ -------- ------------------------------------------- - ---- ------------------------ ---------- ---------------- ,lVraw _ 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 Sari Joaquin Local Heall'h,"District. Home owner or licen- sed agents signature certifies the following: .1 f' "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner m Com laws of California. „i as to become subject to Workman's Compensation p , Signed ----------------- __ __ Owner Title` r Owe - - By-------- (If other than owner) i - �6IC_DEPAJ4MENT USE ONLY APPLICATION ACCEPTED BY -------1.7! ��-------------------------------------------------------------------- DATi BUILDINGPERMIT ISSUED --------- -------- ------------------<�-------------------------------------------------=------------DATI ADDITIONALCOMMENTS-------------------------------------`----------------------------------------- -- --------------------------- ------------------------------- r ---------------a�� ---------•-------------- ----------------------------- Final Inspects Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M -------7------- ---7p -- --------------------------------------- --------------------------------------- ------------------------------------- ----- - `20