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A FOS OFFICE USE: � ti APPLICATION FOR SANITATION PERMIT o� '. ....... _. Permit No. �.Z-.:.z..z.1-... ' (Complete Triplicate) • w -. .-,--,-__ , This Permit Expires i in Year From`D'ate�lssuadr� Date Issued ._ ---l.U:..7..? Application is hereby made to the 5 n Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in'compliance %With��Cqo..�unty'�rd' nce Na. 549 and existing Rules and Regulations: f JOB ADDRESS/LOCATION '"K !j- •CENSUS TRACT .......................... Owner's Name ........ -- Phone 57.- c •....._ Address . ......... ...... ...�� CY.. - City ------------•-- Contract�r s Name .. J - P F .Q.......License # 1 �� Phone Installation will serve Residence❑Apartment House❑ Commercial []Trailer Court .0 Motel ❑Other . _ -�-r------------ - ------ Number of living units!............ Number of bedrooms --.----_Garbage Grinder ------------ Lot SizeZ!e^'�..-►...................... Water Supply: Public System and name ..... ._ ............... --- -- ------- - -----.-----••-_--------- -------- -•--- --------.---Private r Character of soil to a depth of 3 feet: Sand 71 Silt E],. Clay ❑ Peat ElSandy Loam Clay Loom.❑ ' 'Ha dpan❑ Adobe-[7 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 sidel- NEVV INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK-[ 1 \ Size........____-____-- ........... quid Depth + r. Capacity .----.-.- Type _SL•..........`:. .-:. Material_ :• _- __.__-- No. Compartments ...........,-....... - Distance to nearest: Well ....1`.,-......... ,v- ..•x.......Foundation ...................... Prop_ Line ---------•.---._ LEACHING LINE [ ] No. of Lines -------- _._... Length of each 'line ------ --------- Total Length --------- ....... 'D' Box __......... Type Filter Material .......... _.:.Depth Filter Material ............... Distance to nearest: Well --------- .- __-- Foundation-- _"-----._- Property Line ............. .........- SEEPAGE PIT [ J Depth _.............. Diameter .-______-_--. - Number ........__._.__.-..__.-_�-.Rock Filled Yes.❑ No I❑ ,,.--Water Table.Depth ................................ ]-- ----------Rock Size .... . ; Distance to nearest: Well:----7........ ------Foundation ---------aPrrop. Line ...................... Q REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ...................... Date .....................:------------) Septic Tank (Specify Requirements) --. G Disposal Field (Specify Requirements) ___--- _ , -- ---- - --- .............. -----�� ; --� .�t ---------- -------- - - (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 l 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 ollowing:"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 subject to Workman's Compensation laws of Califomia." '�� "' Signed . .. - ,»..7 - - - -- Owner. By .... ...........pG�'✓ . . -...._(�, --- -- Jitle -.. - (If other n owner) _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -...... - -- -••-•---. DATE ��.�.'-'�°T_..• ... ' `..... . . BUILDING PERMIT ISSUED ....... ........................ •---------------•---•- •----_- DATE ............... -______....--•--__...._.... ADDITIONALCOMMENTS - _•......M. ....• , _ _ . - ---- .............................. - --------v•---------------- , -•--...... ............._........__......_------•--•-•.__...._ .•....... ....... .....:: `�....• -------- ----------•------ ---•• ._._.._..---1....._�_.._._..... ........... Final Inspection by: �-,�Q ...............I............... j .......-------- --------- ....................Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M