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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ..................... i -. .... ..........-- -- ----------- Date Issued ' --------.....---------------------I—................... 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: . .- - - - _ _ JOB ADDRESS/LOC N 7 .z. o_...... ........ CENSUS TRACT d "----- - ._.. ---- '.Phone ---••----•----•---------------•-Owner's Name I Addressv� ...�f ---- ------ -- ----- City ,. Contractor's Name -'----' C,tyt/ ...License# -/ � . ..y Phone ' Installation will serve: Residence partment House fl.Commercial []Trailer Court E Motel ❑Other _:_._..-..-• ---------------- Number of living units:------ Number of bedroomsP�_.._Garbage Grinder ------------ Lot Size ..............::......._......_.__.__._ Water Supply: Public System and name -------------------------- - .-.Private I Character of soil to a depth of 3 feet: Sand'❑ Silt o iClay ❑ Peat[DSandy Loam •❑ Clay Loom,7j Hardpan Adobe ❑ 'Fill Material ------------ If yes, type----------_________'..___---- (Plot plan, showing size of lot, location of system in Irelation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: I(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT j 1 SEPTIC TANK[ ] Size_______________________________________ Liquid Depth --------_.---------------- Capacity --__-_-_______-p y .. Type --------------------- Material--------------- - _. No. Compartments ` Distance to-nearest:-Well ----------- --------t---------------Foundation ..____-- -_- --_. ._ Prop. Line ______________________ LEACHING LINE [ ] No. of Lines __ _- _.. . Length of each line--_____________.__...__-_ Total Length ............... d � 4 Box _:_-:.__.... Type Filter Material .............. .....Depth Filter Material 'r Distance to nearest: Well Foundation ______________________ Property Line . -- _-----•-•--------- SEEPAGE PIT [ j Depth ---------------- Diameter ..... Number ............... Rock Filled Yes ❑ No Water Table Depth --------'------------------•-- Rock Size '-•----.__. ..-•- _ . Distance to nearest: Well __... ------------........_._.____-_-._.Foundation .................... Prop. Line ._._._...__.____.____ REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------................ .... Date ..................._.--_--_-__--__I Septic Tank (Specify Requirements) --------- --- ---•- - ----------------------------- - -- ---- --------------------------------- Disposal Field (Specify Requirements) - J�PQ_--- _-- -- 0.---- -------f-------------------------- r -- ----- - ---------- ------ ------------------- -' (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, I shall not employ any person in such manner as to become subjectto Workman's Compensation laws of California." Signed .--'- - - .. ._.. Owner 0 - - - -- wne -• -------------. Title ... d''1r.. - 1 4 By ------ ------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- ---- -- ------ j _ DATE BUILDING PERMIT ISSUED -------------------------------------------------------••------------------••------------------------••-__DATE ....... •---------------_ ---------- � ADDITIONALCOMMENTS --------------•---••---...-- -•-•-----...--•---..__....._.__...---..-_.....---•-----•--------------'-----_--------•..._--•-•------=--------------------------- ..................................... .......................................................................................... -............. - ------ --Z�_le - ............... .............................................................. ---------------------------------------- - ----------•---------• A - Final Inspection by: .----- iCBl t - Date -�.-----`- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.