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�59R OFFICE.USE:rt t APPLICATION FOR SANITATION PERMIT �� (� '� (Complete In Triplicate) Permit No. . ... - 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 is mode:in compliance with County Ordinance No. 549 and existing Rules and Regulations: /L 1i-- S Gly �lnt 2�✓lfL --- ---- - ........CENSUS TRACT --------' --•----'------ JOB ADDRESS/LOCATION .---lt-------- ..........�•%-- Owner s Name .." Zllf'l '--t-../.,. `..�c. .QCIC-'•................---------•-----....•---------- - -- . . Phone ...&__ .__ --'•"' L Address .---'"lZ.---J.41_---;--..5"lh[...1.�._..f.:.li �?.<.._-----..._Ci S'.. .. r.---------"------'- 1//C..._--_- ---..--.License . -?7...4f SfZ. Phone Contractor's Name ..1��------S�P��-'-��' I Installation will serve: Residence WApartment HouseQ Commercial[]Trailer Court [] •I Motel ❑Other ....._...-------------------------- i Number of living units:.".�.--"__ Number of bedrooms --2..._.Garbage Grinder A/ A2. Lot Size ---- Water Supply: Public System and name Private V me ........__-__.----_- ------------"" Character of soil to a depth of 3 fee : Sand❑ Slit❑ Gay 13Peat❑ Sandy Loam [3 Clay Loom 0 Hardpan ❑ Adobe g Fill Material If yes,type ........... ...... --- r etc. must be laced on reverse side.) - IPIoT plan, showing size of lot, Igcation of system in relation to wells, buildings, P NEW INSTALLATION: (No septicltank or seepage pit permitted if public sewer is available within 200 feet,) � Size. ---- -- ---....._...... .- - Liquid Depth - --PACKAGE TREATMENT [ ] SEPTIC TANK'[ } - -"" " Capacity - Type -."- ----------- Material_-"------'-"--- No. Compartments , P b'[- Distance To nearest: Well ._--------.-----_----------------Foundation .-__-----_-.-.---� Prop. Line Total Len th LEACHING LINE [ 1 No. of Lines .--_------.--- Length of each line.._. --------- 9 r ; 'D' Box A...._._ Type Filter Material ....................Depth Filter Material ......------------- ---- -------------- ------- t - property Distance.To nearest: Well _-__..._------------- Foundation -_-_-.-------.•------- PP m' LineL., SEEPAGE PIT [ J Depth `k ... Diametef ....-_._""-"... Number -- -----------------. Rock filled yes 0 No - \1D Water Table Depth ri - Rock Size --------------- -------'..... ` _ ) --- - '----'----�"'--• -•----- - "- v) F Distance to nearest: Well --- �-r�---�- - Foundation ......... Prop. Line .........'-------.... REPAIR/ADDITION(Prev. Sanitation Permit# ----.--- - ------------ Date ........ --_--- ..) Septic Tank (Specify Requirements) .... - --- -m------ --- --"---- ................ Disposal Field (Specify Requirements) "-...n. ff-- _ _ _ - - -- ------ I - - " (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 performl+ce of the work for which this permit is issued, I shall not employ any Person in such manner I as to becom ub[ecf to W rk n6's Compensation laws of California:' Owner Signed _. - - - --- [ -----------_.. Title - ' (If of than ow ell' - . J � R DEPARTMENT USE ONLY DATE ....L/.-............�............. APPLICATION ACCEPTED BY ..:. . ...�......... t.�—}R•r' - - ...DATE ._........-..._...----- ��-�-�---------- BUILDING PERMIT ISSUED ---------•---- -----------------'---'------------ "'--"-'-----"'-""'-'-"--"-......"'-----...---"""----""'-"-- .. -------------------------------------- ........ - -------- -- --------------- --- -_ - - ------------------.--'-------- -- ------ j ---------- --"-- ... ".---------DateQ.-.-' Final Inspection by: -'-- -- -- ..-------- '-'-' 1 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5NL �,•f ,