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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------ "--------------- Permit No,. d- / `r--------- (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Date Issued��._- Q-_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-_Iv__ with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION -----��0--T-___ -._�----- �- ----�- -- ----_------ CENSUS TRACT -------------------- -- Owner's Name ---------- r--Q ------ -- - - ------- -- -------------------- -------------:------ ------ ---------- ---------Phone �--".3c/-71--------- Address ------------ -------- ` 'Cit `� ----- - - ------- Y - ------------------------------------•---- Contractor's Name --------------- --L�/1/L�.cJ ,q-.- ----- - ----- :_. `'- _I.License #16 -------- Phone W67f4!?_7------ Installation will serve: Residence ❑Apartment House-n Commercial >ftrailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units------------- Number of bedrooms ------------Garbage find er ------------ Lot Size!00 �--.--_-_.•.._.- Water Supply: Public System and name ----------------------------------------- ---------------.__.---------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Si it❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material ------------ If yes,type ---------------------------- (Plot plan, showing size 01 lot,'location of system in relation to wells, buildings, etc. must be placed on reverse side.) �I NEW INSTALLATION:. t (Nb,septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT, [<] SEPTIC TANK.'[,]- _ Size------------------------------------------------ Liquid Depth -------------------------- � Capacity -------------.--_-- Type -------------------- Material---------------------- No. Compartments .Distance to'nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --------------- ------ �!'t LEACHING LINE [ ] No. of Lines-------------------------- Length of each line------------------.--------. Total Length ------.----.--_--__------__. 'D' Box --------------'Type Filter'Material --------------------Depth Filter Material ------.---------__----_-----_-_-_.-_--._--- Distance to nearest: W.elil�----------------------- Foundation ------------------------ Property Line .-------_..-._-._-.-.._- SEEPAGE PITDe th :--- Diameter r Number ---------------------------- -Rock Filled Yes No ' [ ) P Water Table Depth ------------"-----------------------------------Rock Size ---- ----------------- - Distance to nearest: Well ----------------I_------_----_-.-----..Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# :..__-y.------------------------------------ Date ---------------------------------- Septic ------------- ------ ------Se tic Tank (Specify Requirements) --------------=------- --- ------------------------------------------------------ ----------- ---------------- Disposal ---------- ----------- ------------------------- Disposal Field (Specify Requirements) ---------- -- ------------------------------ i ---- -Ir`----- ----- ------ (Draw existiirg and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be-done in accordant with San Joaquin Health County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local District. ome 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 any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------------ -- ---------- = Owner BY -------------�� L `----- - ---- -- --- ------------------------ Title --------- --------------------------------------------------- (lf other n owner) - - _'10O;1/DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .-- f --- - - --- --- ----------------- -- ------------------,------------------ DATE 1 G^ a----------------- BUILDING PERMIT ISSUED ------ - --------------DATE ------------------------------------------- ADDITIONAL ---------------------------ADDITIONAL COMMENTS' ---- - ,-- - /3' - -- - -------- -------------------------------------------------- , 7c+--------- --- - -. - -{1t- ----- - ----- �� aec------ll'�' l At---------- o / - ----- +f S� p------- Q - Fin I Inspection b __ ---_ ate __y/ .:f � 0.--._-------------- �' JO QUIN OCAL HEALTH DISTRICT E. H. 9 1- 8 Rev. 5M �� v��/r'�P� Po �u%,! r