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FOR OFFICE USE: �� APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. - ------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued J-J0`_7_d 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 fRI s and Regulations: JOB ADDRESS/LOCATION -_ l � '�y`S '/ - /,�,� �f j ° �", ' :/ . --- ENSUS TRACT --------------••---------- Owner's Name ---�` _ lC fi'� /7_G%' i/-/lr-,57S1 ( Phone --- Address le:, elo e------- < l - - e f City -i ' ------------------------------- -- -------------- - Contractor's Name fl f L< `! •--- -------------License # --t------------------- Phone ------------------- - Installation will serve. Residence P<partment House❑ Commercial [:]Trailer Court Motel ❑Other Number of living units:---- Number of bedrooms ___1_ ..___Garbage Grinder' Lot Size __------- Water Supply: Public System and name ------------------------ Private [ --------------------------- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay [] Peat❑ Sandy Loam ❑ Clay Loam C] Hardpan ❑ Adobe ❑ Fill Material -.---------- If yes,type ---------------------------- (Plot _(Plot plan, showing size of lot, location 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]' f Size-,' �C /r, "-`------- ------------ Liquid Depth -1---_--_- Capacity /2,0-P ... Type �'' �l- Material -�'i f,,__� No. Compartments ----S. ------------ Distance to nearest: Well ". j -----------Foundation __ __--_____ Prop. Line LEACHING LINE �Q No. of Lines ---,2– Length of each line_--� ------ Total Length b' Box Type Filter Materialr�Z?C Depth Filter Material/dr_-�--_____________ __ Distant to nearest: Well 1419— j_ Foundation .. __ ---------- Property Line .>.; �_-�___-_____ SEEPAGE PIT [ ] 'Depth -- Diameter ________________ Number - Rock Filled Yes [] No 0 Water Table Depth -----------------------------------'-------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------__-_------ REPAIR/ADDITION(Prev. Sanitation Permit# --------.----------------------------------- Date --------------------------------Septic Tank (Specify Requirements) _________________ 1 ----------------------------- t Disposal Field (Specify Requirements) ----------------------------------------------------------- ----------------------------------------------- ------------------------------•--------------------.k- ----------------------------------------------- ------------------------------------------------------------------------------ ------------------------------------------------- ------------ ---------- ------------------------- _ - ----------- - ------------------ --- --------------- - --------------------- - ---- (Draw existing and required ad---------------- ---------- - dition 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: 11 4 "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 Compensation laws of California." Signed --- -------------- --- ----------- ---------- I Owner - ---- ------------------------------------- - By - ---------- - ----------- - - ----------------------------------------- Title ....... '.._ (if� r than owner) -------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B - --- �. 2---- DATE _A_ °- -7 ------------- BUILDING PERMI ._0 UED - --- '- ----------------DATE ---------------------------------------- C ---------------------------------------------------------------------------------- ADDITIONALMMENTS.------------------ ------------------------------------------------- -------------------� --------------------------------\ --- --------------------------------------------------------------------------------------------------------------------- - -------------------------------------------------------------------`--------------------------------------------------------------------------- - Final Inspection by: _ __ -------- ----- - ----------- --------- --- - ----- -- - ------- -- - - -- - �------ =-------------- ------------ --Date --- SAN ate --SAN JOAQUIN LOCAL HEALTH DISTRICT 4 E. H. 9 1-'68 Rev. 5M