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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �-:- 5' ¢ Permit No. 4Q �_.6 I (Complete in Triplicate) --------------------------------------------------------- a This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaqui Local Health District for a permit to construct and install the work herein described. This application is ma I' nce�with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . --- `,;/KW.CENSUS TRACT --------------- ---------- Owner's Name _ ----- / fit' - ��J � 'e _- -------Phone ----- Address -- -�4(--�- ----/jv---- 41-� City ' Contractor's Name ___-Xr-/_G�__ _ -�" _____ __ ___ _________ __License # G' _ _ Phone1__. � _ Installation will serve: Residence J'Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other ----- ----------------------------- -------- Number of living units:___ _____ Number of bedrooms --,?------Garbage Grinder W__ Lot Size 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'D] 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'M Size__ _ _--------_------------ Liquid Depth �__�--------.......... Capacity/�21'_L....... Type Otp Material__- _`-___ No. Compartments _ -.............. Distance to nearest: Well -----;P-4__"_ ________-Foundation --------- Prop. Line _ ------------ LEACHING --_-----__LEACHING LINE LA No. of Lines _____�____________ Length of each line----_��_4�---_4__________ Total Length Z .�______________ 'D' Box/Z_J-�__ Type Filter Material r l- epth Filter MaterialZE'_-------------------------------- Distance to nearest: Well -- ---------- Foundation - Line _ ................ --�-=�-�------------- Pro , SEEPAGE PIT ]4] Depth _____ Diameter ___ Number ____Z________________ Rock Filled Yes 2q No 0 Water Table Depth ------7e--------------------------•--------Rock Size ' J--- ------------- s Distance to nearest: Well _____ ___ %___________________Foundation __ :;�_____--- Prop. Line ......... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________--_____________.___-----) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ----------------------------- --------------------- DisposalField (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- ----------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- (Draw existing and required addition on reverse side)" 1 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: "1 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." Signed -------------------------- -- Owner BY ------------------------------- f - ----------------------- Title --- (If oth an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------------------------------------------------------------ DATE f- 1---------------------- BUILDING PERMIT ISSUED ------------ ------------ - -------------------------------------------------- -- -------------DATE ADDITIONAL COMMENTS ------------------ -------------------------------------------------------------�4 --- ------1�--- ---1� --,q---------------------------------------------------------------- ------------ ---------------------------------------------------------- ----------- - _---------------------------------------------------------- Final Inspection b ---zr----------------------------------------------Date f � - - ------------------ P Y: ------------------------- -71 �t--- q SAN JOAQUIN LOCAL HEALTH DISTRICT F E. H. 9 1-'68 Rev. 5M