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FOR OFFICE USE: q'ry� J � t APPLICATION FOR SANITATION PERMIT -------- --- . f? Permit No. --n.,•-r=te- {Complete in Triplicate} -- - ------ --------------- ------- -------------- Date Issued/_,;�.��_t/K --__--_ ------------------------- _----------------- ---------------- This Permit Expires i 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/L_0CATION .- .-----1_.� 1------ �T-`l_-�------------------------------------------CENSUS TRACT ------------------ ` -Owner Namet --------------- ---------------------=- -------Phone ------------------------------ Address --_-- Contractor's Name -- /-1 !--./ X11 ........... ---_-_ --------------- ------.License # -- -1 - - Phone Installation will serve:• Residence' Apartment House,❑ Commercial :❑Trailer Court !❑ r y Motel,❑ Other =- + --------------------------------- -- r a �� Number of living units:_--._ ____-`Number of bedrooms .____Garbage Grinder _.--_ --_--- Lot Size --- -------- -------------------------- Water ----Water Supply. Public System and name --------- ------ -------------------- ----------------------------------------- ------frivate ❑ Character of soil to a depth of•3 feeti—Sancl'0;—Silt El- 'Clay ❑p Peat'❑ " SdJdy Loam ET Clay Loam :❑ Hardpan ❑ Adobe ill Material----- ------ If Yes, type I--------------------------- ` (Plot plan, showing size of lot, location of system in relation to wells,N-buildings: etc. must�be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage it ermitted'if public sewer.is availablewithin 200 feet,)NNN PACKAGE•TREATMENT [ ] SEPTIC TANK'f ] r Size------------------------ ------_.__ Liquid Depth.-------------------------- Capacity -------------------- Type -------------------- Material----------11------ No. Compartments Distance to nearest: Well ------------------------------------Foundatio `- _--- ------ Prop. Li n --_____ e _-- .----- --- LEACHING LINE [ ] No. of Lines -----------—-----'_ Length-of each line.-----___>.________- n _______ Total Length -------_---_ --------------- I 'D' Box --------�__ Type Filter Material --------------------Depth"Filter Material ----------------------------_....._.- � ' -:- -- ----- i ------------------------ SEEPAGE � f ' Distance to nearest: Well -------- ---- -- -- Foundation PropertyLine SEEPAGE PIT [ ] Depth -------------------- Diameter _.--__ _-__--- Number --------------- Rock Filled Yes ❑ No ID Water Table Depth ---------'------------ ------ ---------#----.Roc Size -------------------------------- Disto nce to nearest: Well ---------------------------------- .Foundation -------------------- Prop. Line ---------------- ----- REPAIR/ADDITION(Prev. Sanitation.Permit# -------------------------------------------- Date ------------k_--_--_-_---__-_-----j r Septic Tank (Specify Requirements) ----------------- ------------------- - + =___a =-,V_--- ---� / -- --- ---- ------ Disposal F' (Specify Requirements) ---- -------/_ , .e /�57- - f ------------ ----------------------------------------- --------------------------------- ------ ----------- - ----- ------------------ ---------------------- - --- -------------------------- ------ --------------------- -----------------------/ existing and required addition on reverse side) I t,�y certify that I have prepared this application and that the work will be done in accordance with San Joaquin a -Co,unty Ordinances, State Lal+s, and Rules and Regulations of the San Joaquin Local Health District. home owner or iicen- sedii gents signature certifies' he following: 41 I�L' i :..wr1- _. �... .....� .w.Vw....�,...x-v +w.,...--w+ sr_+wr..r. I certfy that in the performance of the work for which this permit is-issued, I shall not employ any person in such manner as pfo becorn object to Workman's Compensation laws:of California." Sigiled - - ------ ---------- - --------------- - Owner ---- -------- - t BY Title ------- ---------------------------------- (If other owner) FOR DEPAitT.MENT USE ONLY APPLICATION 'ACCEPTED BY -_______ �,� - - ------- ------------'--------- ----------- DATE -/'2 -�' -�---•--------- -- BUILDING PERMIT ISSUED ----------- ----------' - ---- ---------------------------------------DATE ------- ' ---------------------- ADDITIONAL COMMENTS 4t�.-- c- ---------•----------_ - ---------------------------------------------------------------------------- --- ------- ----- --------------------------------------------------------------------------- -- - - ---------- -- ---------------:------------------------------ --- ------------------------- -------------------------------------------------------------------------------------------- -- --------------- ------ ----- _ ----------------- --- ---- - Final Inspection by: -- ---------- t ---------------------------------------------------- gatee `'r f SAN JOAQUIN-LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.