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FOR OFFICE USE: APPLICATION�'F`�OR SANITATION PERMIT - _ : ---.-_.--~�- (Complete in Triplicate} it No ----------------- -- ----{l/�-'��-------- � . � Perm _„� .. issued----�_-a ' 7 L A afe Issued; Dat PI a 'I This Permit Ex Tres 1-Year From D L # Application is hereby made to the San Joakquin Local Health C]Jstrict for a per toy construct'`and' install the work herein" described. This application is,,made in compliance with County O'rd:inance:No. 549 and existing Rules and,Regulations- JOB :ADDRESS/LOCATION i--- ca U �� ---:i.--------------•-..CENSUS'TRA_CT_0-' ? , Owner's Name .----C'�-- . = ��'1'� --- •-�.. 777.t_- Phone qc� Address .------ City --------- ------------------•-----•-------• " Contractor's Name __ ----------------License # Phone, r Installation will serve: Residence'❑ Apartment House[] Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- , 1 Number of living units:�__ Number of bedrooms __ --'__Garbage Grinder -_- _._ Lot Size ___ ____------;- Water Supply: Public System and name ------------------------------------------------------------------------- = = `.Private A Character of soil to a depthi'of 3 feet:'" "Sand'❑ Sift❑ Clay ❑ Peat❑ -:Sandy Loam ❑ Clay Loam:❑ Hardpan ❑ Adobe'Nf Fill Material ____________ If yes,'type ---'____________ ___________ (Plot'plan.,`showing size of lot, location of system In gelation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit{permitted ifspublic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Y� Size `- {t' __________- -�f_,_____ Liquid Depth _____________---__,...__ _ No. Compartments ........ .............Ca Capacity Pe 1 - - Material, 11 - Distance to nearest: Wefl.v_______________________ ______Foundation 3�'__`_'_______________ Prop..Line _____________:________ •1. �V LEACHING LINE [ ] No, of Lines ------- -- ----- Length of each line ___#______ Total Length- __.. ...................... _ [ 'D' Box ------------= Type Filter#Material Filter Material�t=------- �- - Distance to nearest: Well __________ __________ Foundation ________"-_`--------- Property Line ____-____-_----__-_.-__ SEEPAGE PIT ( Depth e �_ Diameter .il '!!_- Number -_-------- . ,t. No .0 `I p ___-_ - ___ _ ,_ _ �___ .;_ 'Rock Filled Yes , / . = Water Table Depth ------------ --q_- ,------Rock Size :! -;--._--------------- ------ i Distance to nearest: Well ______,: r_��-- ` ------r______Foundation __/ __�_ Prop. Line __ _�, �_.. r f ( REPAIR/ADDITION(Prev. Sanitation Permit# --------------------- ------- =_-- Date ------------------------------_-_-) Septic Tank {Specify Requirements} -•------------`---------- "-`-------------------- ----------------------------•----- - --------------- ••------------ --- ------ I Disposal Field (Specify Requirements) ----- = :t - ------ i.� ---------------------------------------f-- r '- ----------------------------------------------------'--------- . (Draw existing and required addition on reverse side) t 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: t ;� "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 ------------------- ------ --- ----- Owner i --------------------------------- R I ; BY =--E--- -------------- ------------ ------ ------------------------------- Title ----- ----- -�.r- (If other than owner) : M + - EPARTMENT USE ONLY APPLICATION ACCEPTED BY -- -------------------------- ----------------------. DATE - = - �'----- ------- BUILDING PERMIT ISSUED ---- - ---� - --- -- - - - ----- _-DATE ----------- ------ ADDITI� � --------------- ADDITIONAL TS��=---- - .--- - �' ' -- - -- Tit S �__1 ��-=------------------ - tt -- --- 7` -- -----)- )----r----- _,: a - v - - - ----- ------------------------ --- ------ -------W�10--U/1/-7 Inspection Y. -- - ------------------------------------------------------ ------------ FinalD to J AQUIN LOCAL HEALTH DISTRICT 1 l.H. 9 1 '68 Rev. 5M �. r