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FOR OFFICE USE: APPLICATION'FOR SANITATION PERMIT �. .. - - (Complete in Triplicate) Permit No. ------ -- -----------------------------------'- ---- - - . �( _41 Date Issued 1-�:;6-b_. _______________________________________ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a Pp Y q permit to construct and install the work herein describecl. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: F JOB ADDRESS/LOCATION .-- -- __��--------- r-_--- - _f-- l~' t____ ------ � - /� - - - ------------------- CENSUS TRACT -------------------------- Owner's ----- --- ...---------- Owner's Name f-r �. _ - Phone Address' ddresse , -------------------------------------- City e , Confiractor's Name , - - ------ /��------License# -1r`! a�-- - Phone _7_4�`31�� Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other ---- ------- ----`__-.- ---- Number of living units------------- Number of edrooms -- ------ Garbage Grinder ------------ Lot Size _ - -o, �� E Water Supply: Public System and name y_ '-E"-------------------------- --•-- •------- ----------------------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt E] Clay ❑ Peat❑ Sandy Loam E] 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.) � r NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ..{ I PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size_________________-_--__------__----;_._--------- 'Liquid Depth ------------- ------- ---_ Capacity -1---- ------ Type Material-----------------4--- No.i Compartments -.----- Distance to nearest: Well - ---------------------------------- - -..__Foundation ---------------------- Prop. Line;----------.-.--•---•- LEACHING LINE [ ] No. of Lines ------------------------ Length{of-each line---------------------------- Total Length 3------------ ---...----_------ 'D' Box ._-1___------ Type Filter Material--------------------Depth Filter Material ---------------------------.——......... ._-_-- .{,# Distance to nearest: Well --------------- ----- Foundation ------------------------ Property Line. _-----_----._--_-----_ SEEPAGE PIT [ ] Depth ----i--------------- Diameter ---------------- Number ---------.------------------ -Rock Filled Yes ❑ No i❑ Water Table Depth -----------=''-, 'r`= ------------------------Rock Size ----------------------- -------- I Foundation Distance to nearest: Well ---�_----�----=-----------•-- -------- ------------- ------. Prop. Line ---------------------- '3 tw REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------'-------------_----- -- Date -----------------------•- --. `..:} , f "r Septic Tank (Specify Requirements) -------- ----- -------------------------------- --- ,,-------------• —---------------- -------------- ` Disposal Field (Specify Requirements) 4 --- ------- --------------- ---------------------- - - - -------------------- ---------- i ----- ----------------------------------------- --------�----------------- ------=------------------------------------------------ .� I (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 wner or liven 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." - �k ` • ` � Sig y ^ _ Her. #..� �,�. 1 BYitle ------------------- - ---------------------- (If - , other than owner)j 11 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------! ___�_-_--._ - __ __-_- - - - 0m---------------------------------------------------------- DATE --- --- --�---6 �----------------- BUILDING PERMIT ISSUED ---------- - --"--------------------------------------------------•---------------'-------- ------------`-DATE ---------------------------------------- ADDITIONAL COMMENTS - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ---------- --------------------------------------m---------------- ---------------------------------------------------------------------------------- -S ' - - --------- ---------------------------------------- Final Inspection b Date __- l_-- ' -- ------------------------------------ - ----- -------------- -- ----- ------- --------------- ---------- - - p Y = - � SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M