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FOR,OFFICE USE: APPLICATION FOR SANITATION,PERMIT w (Complete in Triplicate) V Permit No. .__7L'- L3 ___._.____-____ ___.____ 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOCATIO Y0 =L_# r;{��f ---/- -1 t -&,-- --------- ---------------CENSUS TRACT Owner's Name .-- --- - -- -------------------------- -------Phone.!?3/_�-.. e--------- Address V--;- ----- . City GG Contractor's Name ----------------- -------------License # 1 _. �I---- -- Phone V'(6_--F -------- Installation will serve: Residence j� ❑Apartment HouseCommercial ❑Trailer Court i❑ i `►v t "Motel ❑Other -------------------------- ----------------- Number of living units------------- Number of bedrooms -- _..Garbage Grinder ___________ Lot Size _._____ __________________ Water Supply: Public System and name ------------------------------••-- --------------------------------------------------------------------- ------Private -o--�—Gharacter-of-soil-to-o depth-of 3�feet. ;.;..Sand-❑•—Silt-E]—-Clays{] ,,.Peat-❑,;.�,Sondy+Loam-O Clay Loam,Q--,",�„�� Hardpan ❑ Adobe Fill Material ------ If yes, type ___________________________ (Plot plan,. showing size of lot, 'Ioca,tion of system in relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION. (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] "Size-----------------------------------.------------ Liquid Depth --------.-----.-----,_---- Capacity ---.------------ --- Type --------------------- Material---------------------- No. Compartments ------ ----•- .i _ f Distani a tdlnearest: Well ------------------------------------Foundation --------------- ------ Prop. Line ----_-_----------- LEACHING LINE �[ ]� No. of Lines --------------------- -- Length of each line---------------------- -- Total Length .----------------------•_--- D' Box -------- --- T e F �yp Fi ltelirrMaterial----- ' t -------- -------Depth Filter Material ------------- - ' ------------------------•------ Distance to nearest: Well ________________________ Foundation ------------------------ Property Line -------------------------- SEEPAGE PIT [ ] Deptli ____________________ Diameter ---------------- Number ___' --------------------- Rock Filled Yes ❑ No Water Table' Depth ------------------------------------------------Rock Size --=---- -------------------- t r Distance to -r earest: Well _-__�---------------------Foundation _________._ -------- Prop. Line ..................___.. } �.. Date ---------------------------------- --------------- REPAIRJADDITION(Prey. Sanitation Permit # _______ ________)il--.____ ) Septic Tank (Specif� Requirements) ---------- ---------------------r'� - ----------- Disposal Field (Specify Requirements) '" " -----------yo- -------i. y' _---__ ___""- ----------------------- j ----------------------------------------------------------- - --`---------------------------------------ID --- - -------- - --- ---------------- ------------------- (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 .foaquin Local Health District. Home owner or liven- 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 Comperisati.on laws of California." I B g -------- A ----------------------------------- - Owner.,; Signed __.___/_ _ { �L.r � , Y --------- Title _ < (If of than owner) FOR,DEPARTMENT USE ONLY.- APPLICATION ACCEPTED BY ---- -- 54-P---------- _ '`= w=: �.: DATE � '7J------------ -----------------------------------------------------------------PERMIT ISSUED —,A. _^ �_�.� �._ `'_. . __ -�--------- - --------------- ------------ 7;-------- -- ADDITIONAL COMMENTS "Q"^^ _ r____ w ---- ------ ------------------------- ----------- ------------------------------------------------------------------------------------------------------------------------------ - - :.. . --------------------------------------------- ---------------------- ----------------------------- -- ------------------------------------- - --- --------- - if Final Inspection by: = --------------------------------------- --------------------------------Date ....... ---- --- ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M _