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FOR OFFICE USE: 5_ t M APPLICATION FOR SANITATION PERMIT , � _ � -----------�-��- &--------- - ' �u __ 7A. (Complete in Triplicate) Permit leo_ ____________ ____ ___J Date Issued_5 4A�, _ ---------------f-------__------------------------------------------- This Permit Expires ] Year From Date Issued t 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: I __ CENSUS TRACT___ __________�:..._.-- JOB ADDRESS/LOCATION ��9'/--- ------ --------- ---- -- ------------------------ -- -�� --------- Owner's Name _ �'_ __ Phone ------------ ------------------------- ------ �71`f------ Address -4;—e ----- -- -- ------ ------------------------- City -------- -- ------------------ a S - Contractor's Name __ _/' _-___ t¢�7 __ __ Q�fS�___Z�C-__-_-.License # t.----V Phone Install Icition will serve:—Res idence)i�jApdrtment-House°❑-Commercial"❑Trailer"CAet"❑T ` M t ---------------------- - � Motel ❑'Other �_____ Number of diving units:--_�_-_�- Number of bedroo s ="Garbage Grinder _____.:_= ~L'ot Size _______--:'._. Water Supply: Public System and name --- u-li _: ---"I "------------------------3_-_ - ---------------Private ❑ Character of soil to a depth of 3 feet: Sand_❑ Si!fl'' Clay-❑— Peat❑ Sandy Loam 0 Clay LoamEl �.. - Hardpan E]--�Adobe FFill Material __"-_�_____ if yes,type -----------------.---------- 0'6t plan, showing size of lot, location of lystem' in_ ielbtio'n'to wells, buildings, etc. must be placed on reverse side.) 1 NEW INSTALLATION: (No septic tank or seepage pit perir itted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK'[ I Size------- --------------------------------------- Liquid Depth -----------------'---.----- Capacity ------------------- Type - ------------ Material---------------------- No. Compartments ------------------- Distance to nearest: Well A---------------- ----------------Foundation ---------------------- Prop. Line ---- _--- {---"_""-- LEA'CHING LINE [ ] No. of Lines ------------------------ �L•ength of each line---------------------------- Total Length ,______._ 1" D' Box ------------ Type Filter Material ---------- --------Depth Filter Material -------------------------------------------- Distance to nearest: Well ------------------_---__ Founldat on ------------------------ Property Line ______________------_ SEEPAGE PIT [ ) Depth ____________________ Diameter --------- ______ Number' -------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ___________--- -- - -----`------------........Rock Size -------------------------------- ------------------------- ----- Distance to nearest: Well ------------------------I------"-j__--Foundation -----------------e- Prop. Line -------•---....._.---- ( ° r REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________�,__-----__---_.-- Date ----------- ------------- Septic Tank (Specify Requirements) ---------------- ` -------------------------------- '---------------- ------------ ------------- Disposal Field (S cify Requirements) -Qs- ------�----------- ---------------------- -------------I--------------•I------------------------ - (Draw existing and required ad�di`tion on reversesiif 1 hereby certify that I have prepared this application and thaThe work will lse)done in accordance with San Joaquin Courity Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. dome owner or licen- sed agents signature-certifies the-following: - --� "I certify that in the performance of the work for which this p mit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----------------------- -------------------- Owner f � Y -- ---------------- -------- -------- Title ------------------------------------------------------ f other than owner) WWRTMENT USE ONLY - APPLICATION ACCEPTED BY ------ - =-- - -------------------------------- ---------------- DATE aS' g� BUILDING PERMIT ISSUED -------- ---- ---- r ,� ,' DATE ------------- ----------------------------- ADDITIONAL COMMENTS ------- --- - -- ------ ----- ---------------------------------------------------------------- --------------------------- -------------------------------------- -- --------------- - --- - - - -------------------------------------------- - - -- --- --- ---- - -------------------------------------------------------------------------------------------------------------- -- -------------- --------------------------------- - - -- -- - ----- ---------------------------------------------------------------------------------------------- � • ----- Final- ---- Inspection b ------------------------------------- �i p Y� ------- - -------- -- - - - -------- - -- - - ---------------- ----.Date S JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Re . 5M j