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� , 1 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------- --- Permit No: 3- - {Complete in Triplicate) . ------... ---- --- ---------- `-------------------------- r 73 { Date Issued F _. --------- --------------------- ------------------------- This Permit Expires 1 Year From Date Issued e Application ill.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: IIIIhh I JOB ADDRESSAOCATION .---:----1 1-_-- J____�� __r .",-P`c---- ------CENSUS TRACT ----------------------:--- Owner's Name _:.__/Y _ u ��f�---------------------------------------- - -------- Phone Address ----- - cam` ' I�---- ----------------------------------------------------- City ---------------------------------------------------------------------------- Contractor's Name --------- '-------------- --- ------------------------ --.License # ------------------------ Phone ---------------------••-•----- i Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court n Motel ❑Other -------------------------------------------- M� g --- IM ----Garbage Grinder ------------ Lot Size ------------------------------------- hEumber of living units:-__ --_- Number of,hedrooms ________ _ _private Water Su I Public System and name ------ --- ----------------------------------------------------- Character of `soil to a depth-of-3 feet:L Sand. Silt❑ Clay ❑ Peafi❑ Sandy.Loam ❑ Clay Loam ❑ 'Hardpan E] Adobe,E]'. Fill Material ____________ If yes, type may. fir_ r iM. (Plot plan, sky\,,;-ng,size of..Iot, location of system in relation ,to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (o septic tank or seepage pit permitted`if public sewer is available within 200 feet,) "I [ ] ',,.,,"Size-------- -------------------------- ------------ Liquid Depth -------------------------- PACKAGE.� _ ""-_ Type ______"""--- TREATMENT EIMIC TANK yp ------- Material________-_._________ No. Compartments ---------------------- Capacity I - 6 IF �. } Distance :I o nearest: Well ____________________________________Foundation ---------------------- Prop. Line ------.______:___-:--- S LEACHING Li„ E [ ] No. of Lines ________________________ Length of each line--- ---------------- Total Length ,____"____-____------------ C 'D' Box -11---------- Type Filter Material --------------------Depth Filter Material --------------------------------------------- G Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ..______-----_____-.__-. SEEPAGE PITS: [ ] Depth/1-11---------------- Diameter ---------------- Number -------------------------- Rock Filled Yes ❑ No .i❑ Water Table Depth ---------------------------------------------_Rock Size --------------------------------- Distance ------------- ----------------- Distance to nearest: Well _______________________r______--_. _"Foundation ______._.--- Prop. Line --------- ------------ i y I� _ REPAIRfADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---.-----------.--_------------- } � F SepticTank {Specify Requirements) ----------------------------------------------------------------------•;--------- ----------------------------- ---- ----------------------- f. Disposal Field (Specify Requirements) .__. cry--� r�� G��- ---------- �- '* - �_ ry ` ----------- ----------------- _ -------------------- ---------------- N {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 Son 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 tit performance�kof the work for which this permit is issued_, I shall not employ any person in such manner as to be me s le t to Work_ s Com ensation laws of California." Signed -X- J! --- ~ Owner I� --------------------------------------------- (If other than owner] ' I FOR .DEPARTMENTt USE ONLY I .��- ------------------------------------------------ ! --- APPLICATION ACCEPTED BY ------�--- ----- - -------5�_�� . DATE -----�-=-1-- �v BUILDING PERMIT ISSUED ----------�I-------------------------------------------------------- -----DATE ----------------------------------------- ADDITIONA� COMMENTS ----------4 - ----------------------------------------------------------- �I-------------------------------- ----------------------------------------------------------------- -------------------- ------------------------------ M--------- --- -------------------- --------------------- -- --- -- -- - - - i Final Inspection by: ------ --- --------------------------------------Date --' -- ---- SAN JOA IN LOCAL F{�ALTH DISTRICT E. H. 9 i1-'68 Rev. 5M _n:r�