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FOR OFFICE usl_: APPLICATION FOR SANITATION PERMIT --- ----- ------ ------ ------------- ---------- Permit No: f (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 iis•m ade in compliance''with County Ordinance No. 5.49 and existing Rules and Regulations: JOB ADDRESS/LOCATION _�, ��--111Oz ° /� ,f-lrl- ------------------- - CENSUS TRACT f i ---------.Phone 99W__-�------- Owner's Name --------------------------- -------------- Address -- ------------ Address �.�"�.� `�� '"""' --- --- -- City --------------------------------------------------- .CDD/ Contractor's Name ----------------------------------------------- -------.License # 177-8V--- Phone 7----?Z ----- Installation will serve: Residence [�partment House❑ Commercial ❑Trailer.Court 'El Motel ❑ Other -------- ----- - -------------- -- - - I ` Number of living units:"".-/-.-_- Number of bedrooms ----/-----Garbage' Grinder -/��"- Lot Size fo�0-�".60---------- r 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 Vj- 'Fill Material ------------'If yes, type -------------------------- (Phot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on +everse :side.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) N PACKAGE,-TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------- --------------- Liquid Depth ---'----------- Capacity -------------------- Type -------------------- Material---.---------- ------- No. Compartments ---------------......... Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ..-----------------:--------- ' 'D' Bzox _'_=_ --- _ Type Filter Material --------------------Deth Filter Material ------------------- --- ------•=-•---•--- + Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ----------------------- I ------------------_ I Rock Filled Yes No i❑ SEEPAGE PIT [ ] Depth --- Diameter ---------------- Number ------------------ ❑ _ ----------------- WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance ----------------_--Distance to nearest: Well----------- Foundation -------------------- Prop. Line --..------------.--.-- REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------"------------------"- Date ----------------------------------) Septic Tank (Specify Requirements) ----------- -------- -----------------I------------------------------------------- ---------------------------" ------------------ -------.- O Disposal Field (Specify Requirements) //0----- C/y1/ltd0� --- --02 X,�- ------ -------- = 4 k ------------------------ ------------ ---------------------------------------------------------------------------- ----------------------------------------------"----------------"--------------------------------------.-------- (Draw existing and required addition on reverse side) I hereby certify that I 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, 1 shall not employ any person in such manner s to becom subject to Workm n's Compensation laws of California." a Owner Title -- (If other than owner) ' O D ARTMENT USE ONLY DATE ------r :��_7K.,4 APPLICATION ACCEPTED BY ---------- --------- "---------------- ------------------------- BUILDING PERMIT ISSUED ------------ - ----- ---- -- ---------------------------------------DATE -----------•---------- ------ ----- ADDITI COMMENTS _. AQ--- ---- ------t-�7--------=---4--�--1---�----a---9-'----f--4--------4-t-------a--l--t---- -- C� < ----/--�--d- r / --- ------�,, ,a ------- --------� < � - -f } ---------- iia"`I -Date -- -------------- -- UIN L HEALTY DISTRICT t 6 'H,1�►{v1 1-'68 Rev. 5M