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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. .71.= 3 _. ---------------------------------------__._----_-__---_ This Permit Expires 1 Year From Date Issued `�`f_ Date Issued __� 7 - 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 complliiiaance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOC�ON -------------42�55_/_-_—V- 'A q --------- ---------- CENSUS T RACT --__ _ _ -- ----------------- -----S------------/-- * ---- -- -- ----- PhoneOwner's Name ---f Address -------- ------------------------------------------- --- Contractor's Name -----.:�7a/_oo------ ---------------------------------------------------------License # -------------------- --- Phone -----------------------.---_- Installation will serve: Residence ❑ Apartment House�❑ Commercial railer Court ;❑ Motel ❑Other -------------------------------------------- Number -----------------------------------------Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ------i _1141-_i�_____________.__. Water Supply: Public System and name ------------ ---- ---------------------------------------------•--------------------------------------.Private El- Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe #] Fill Material ----- ------ If yes, type ---------------------------- (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 seep pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK:[ Si ________________________________________________ Liquid Depth -------_----___.____,_____ Capacity 11m---------- Type(? Oro-IJ------- Material row-G - No. Compartments -2 t' istance to nearest: Well ---------------------Foundation ---Zp------------- Prop. Line '�________ p A f LEACHING LINE No. of Lines ------ ---------- Length of each line------7f?________.______ Total Length ---ol_ -______..._.___.. 'D' Box -lal ____ Type Filter Material -.Depth Filter Material -----/Q'- a, Distance to nearest: Well ___________ Foundation _A0 ----------- Property Line ______ __ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------. Number ----- --------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size ------------------ --- Distance to nearest: Well ________________________________________Foundation -----------------— Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# __------_----------------------------------- Date -------------------------.--------) SepticTank (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 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 becom subject to Workman's Com enaation laws of California." Sig ------ r'��?!- ----------- ---------------------------------- Owner By ------------------------- --- -- ------------------------------------------------------ -------------- Title --------------------- -------------------------------------------------- (If other than owner) FOR DEPA-RTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------- ---------- f -------------- DATE ____1: 3." /____.-______-_ - ------- --- ----- BUILDING PERMIT ISSUED ------------------ -------------------------------------- - --DATE ------------------------------------------- ADDITIONALCOMMENTS ------------------------------- - ---------------------------------=------------- -•----------- --------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- ------------------------------------------ ---- ---- - - - --------- --------------------------------- --- ------- Final Inspection by: ------- - ----------------------------------------------------------------Date --' _ - - ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M