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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT QQ --------------------------- --------------------------------- Permit No. (Complete in Triplicate) ----- Date Issued ------------- - - ------------------------------------------------------ -- _----_-__--------------------------_--------_-_---_---____ This Permit Expires 1 Year From 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 ADDRESS/LOCATION . CgiPA" a --------------------CENSUS TRACT ------ ------ Owner's Name ------ _ ------------------------------------------------------------ -----.Phone WA Address ------------------------------- ---------------------------------------'------------------------------• City ---7G = ------ Contractor's Name .----------------------------------------------------=-----------------------------------License # ', _�] .__ Phone . _ R� Installation will serve: Residence ❑Apartment House❑ Commercial :❑Trailer Court Motel ❑Other ----------------------------------------•- Number of living units:_._. _____ Number of bedrooms _,____Garbage Grinder ---------- lot Size __ _ 9�___________________ Water Supply: Public System and name ---------------------- ------------ ----------- --------------------------------------- ----------------------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe X 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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size--- ------ Liquid Depth ------ .f----------- Capacity _ _______-Capacity ��.(,7__ _ ' Type ��r hlld4ei•i6l___=__7"-'-_---___ 'No:-Compartments f s Distance to nearest: Well ______ ___________________________Foundation ----------`__ Prop, Line ___:0_-.:....,------ LEACHING LINE [ ] No. of Lines ----- ______________ Length of each line---------- Total Length ....________.- ] 'D'~Boit,-----j..... Type Filter Material I!' XDepth Filter Material _� f�_r- _______________________ a _ Foundation . 7 pistancelto nearest:Well.--=;�-------------- -- -�L'�_________------ Property Line. __-` ----------•-•-- SEEPAGE PIT [ ] 'r Depth.,.(_._--J-,--------- Diamdter _______________ Number ---------------------------- Rock Filled Yes ❑ No i❑ Wate-r fiWe Depth. ------------------------------------------Rock Size L. Distante to nearest. Well -----------------------------------------Foundation Prop. Line ____-..---______.___.. REPAIR/ADDITION(Prey. Sanitation Permit# ________ ----------------------------------- Dafe --_=____-_--------------------- Septic Tank (Specify Retluir mentsi ----------------------- ------------------------ ----------------------------- f. i 3 �` ------------------------------------. �� ------------- ----- � Disposal Field (Sp. 4i y` Requirements --------�-----------------------o. r-----�------------ti----------- . 1 ------------------------ ------------------------------------ ----------------------------------------------------- (Draw existing and required addition,on reverse side) i land that the work will be done in acc�rdance with San Joaquin I hereby certify that ,I have prepared this-.app "ication County Ordinances, State,Laws, and-1ules and Regulations of the San-Jociquin Local Health District. Home owner or Iicen- 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 subile 'to orkin 's Compensation laws of California." Signed � X24'G2 ---------------------------------------------------- Owner BY -- -------------- i--•---------- - i' ------------------------ Title ...... -------- ----------------------------- -------------------------- (If other than owner) S � 1 r FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY4 - DATE ------------------------------------------ I BUIL-DING-.PERMIT.ISSUED---------------- -_ - ------- --- - -- -. ----DATE ----- --------------- ADDITIONAL COMMENTS _____________________' ' 2 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ _ - ----------------------------------------------------------------------------------------- ---- --------------------SL. - - ---Final Inspection by: --------------------------------------------------------------------- •-------- ------- Date ---- ------------- -f� f .. SAN JOAQUIN LOCAL HEALT TRICT E. H. 9 1-'68 Rev. 5M