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FOR OFFICE USE: APPLICATION 'FOR SANITATION PERMIT . Permit No. ---------------------` r (Complete in Triplicate) ------ � This Permit Expires 1 Year From Date Issued Date Issued }e Applicationris hereby-maderto 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 ADDRESS/LOCATION ------ ---------Ur -(�---- eY �_- - h -1J ' -- ' �hj'--CEN@] TACT --------------------- - f --- Owner's Name --------FZ"X---- �4C-k1 ;.,°A-- Phone a Address (€�"ocy "" L� -------- _Aa .....__ _ __ . Contractor's Name --->-dQ-��---F-7ul_La-J�---------------------------------------------License Installation will serve: Residence;9 Apartment House,[-] Commercial❑Trailer Court ',❑ i S Motel ❑ Other -------------------------------------------- Number of living units:_.j---- Number of bedrooms _Z------Garbage Grinder __________ Lot Size _________r_:_._____s'' ------------------ r Water Supply: Public System and name ------------------------------------- -------- ----------------------------------------- Private_ Character of soil to a,depfh.,of 3 feet:: Sand% Silt,] Clay ❑ ' Peat❑ Sandy Loam ❑ Clay Loam ❑ r - #' Hardpan ❑ Adobe'❑ Fill Material __ ---__._ If yes, type ------------- _ _-__-- - - ! (Plot plan, showing 'size of lot, location "of system in re ation to.wells, buildings, etc, must'be placed on reverse side.) NEW INSTALLATION:' (No septic tank or seepage pit permitted if public sewer is available wifihin 200 feet,)/ - 1 ' ' PACKAGE TREATMENT { ] SEPTIC'TANK_'[] ` 'Size-------------------------- ------- :-- Liquid Depth ---------------------- ' Capacity ------ Type _____---------------- Material- ---------------- No. Compartments -=---------------=---- 1 Distance to nearest: Well ------------------------------------Foundation ---------------------- Prgp. Line.. j --------- y LEACHING LINE [ j No. of Lines __4 _.k_ ______________ Length of each line______ >._.. - _Total Length _________-- Jr D' Box -------------:Type Filter Material ---------------- :-Depth Filter Material, .......... --------•---------------_._.--- - Distance to nearest. Well ::______________________ Foundation ____ _:_________,____ Property Line __..__...._.._ ... SEEPAGE PIT [ ] f Depth --------- ------9z,_ Diameter ---------------- Number _. . .'_`______.._1____ Rock Filled Yes ❑ No ❑ 1b Water Table Depth' ------------= --------- Rack Size-.'.: --------------------- i- - i Distance to nearest: llVefl ------------------- Foundation ................. -----`-------s___ Pro , Line ---------------------- REPAIR/ADDITION(Pre'v. Sanitation Permit# ......z= -c--�^-- rte.___ Date _--_______-- -------- Septic _ _Septic Tank (Specify Requirements) -------------------------------------- -------------- ----- -------------- -----------=-- !6 Disposal Field (Specify Requirements �,.... , �_ �.... -L '� _i�rk _�-_'__' t•_-------------------------------------- -------------------------------------------------------- __ ____ ---__-------- - - f. -------------------- --------- --------- ------- -- i 4 --- ---- , --------- _ _ _--------_----__________________________________________________ _ (Draw existing and required addition on reverse side} I hereby certify that 1 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 become sub' ct to Workman's Compensation laws of California," Signed __ ii a ---------------------- ---------=------------------- Owner BY ------------------------ -------------------------------------------------------------------=------- Title --------- ----- --------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ --- ------ --- ---------------------- ----------------------------------------------- �� 7 - -------------- DATE ---�--- ----- ----- - -L ----------- BUILDING --PERMIT ISSUED ---- --------------------- ----------------------- ----=--DATE -----------------------•------------------- .ADDITIONAL COMMENTS -----=------------------------------------------------------------ ------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- -- � Final Inspection bye ---- ---- �� ----------------------------------- ----- ----------------------------- -----------•---------------------------- Date._ 1 --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.