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FOR OFFICE'' USE: APPLICATION FOR SANITATION PERMIT ----------------�._. `------------------ ------ Permit No. 22- �-+ - . -7 {Complete in Triplicate} , ------------------- ------------------------------------ This This Permit Expires I Year From Date Issued Date Issued:.-Z o=_T-- Application is hereby made to thaquin 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 ADDRESSAOCATION ___6426--------`�......Q00----- C1 ---------- ---------- ------------------CENSUS TRACT -------------------------- Owner's Name ----- O—Z0--- 15--if11�I-� ------- --------- -------------------------- -------Phone ----------------------'----------------- Address r1 W I Q----��----�f--------------------------- City �a7 Q-CI�C.T /l! t- ------ 4 '-------------- Contractor's Name Contractor's Name F�J l- Sr � /-/Ll��/n.0 Li.ense #Zt' Phone Installation will serve: Residence [y Apartment House[] Commercial ❑Trailer Court ;M Motel ❑ Other -------------------------------------------- Number of living units:---------- Number of bedrooms --.0_--_--Garbage Grinder ------------ Lot Size -_---_------_-___---_----------------- Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet; SandE] Silt❑ Clay �K Peat❑ Sandy Loam .❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ 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: fNo septic tank or seepage pit permitted 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 --_--------------------------------Foundation ---------------------- Prop. Line --------- _---_--_ 0 LEACHING LINE [ ) No. of Lines ------------------------ Length of each line---------------------------- Total Length ---------------------------- 4N 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------_--- SEEPAGE _--_--_--__-._ --_SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------------------- Rock Filled Yes ❑ No C Water Table Depth ------------------------------------------------Rock Size --------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---_---_-_-___-__---_ REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements[ ---------------------- ----------------------------------------------------------•------------•-------------------------------------- ---- - / ti r Disposal Field (Specify. Requirements) _-x10..-_-_--_--_�e��--- AG<f , �,is --.--/�s�P� />� T �?'X2$ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 as to become subject to Workman's Compensation laws of California." Signed ---- - -------- -- -- -- Owner BY --- Title -- C®IVi2.41G- 'C (If other t n owner) FOR REPARTMENT USE ONLY APPLICATION ACCEPTED BY . e-16-1------ -- - - ------------------------------------------ DATE t= �2-------------------- BUILDINGPERMIT ISSUED ----------- ------------ ----------------------------------------------------------------------- -------DATE ---------------------------------------- ADDITIONAL COMMENTS -----------------------�- - �/ - `• >`� 'J`" �---------------------------------------------- -------- ------------------ - --------------------------------------------------------- -- - - - -- - - - - -------------------------------------------------------------------------------- --------------------------------------------------------------------- - --------- ----- --- --------------------------------------------------------------------------------- ------------------------------------------ -- ---------- - - - ------- -- --- ---- ----- Final Inspection by. - ._ -- Date - v SAN J QUIN LO HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M