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FOR OFFICE USE: / APPLICATION FOR SANITATION PERMIT Permit N06�� __ TTT� ,/ - R (Complete in Triplicate) ------------------------------------------------------------ This.Permit Expires 1 Year From Date Issued 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 TEON,. O 3 r' �-� ------------------ TRACT ----------- Owner's Name --------------- ; -`-------------------------------- --_- -- - -----------Phone---------------- Address __.,Saz_, r City Contractor's Name -- - - f✓-__ �'_��_-�.�-Q, ---------.License # �Syl7.--4--- Phone Installation will serve: Residence>rApartment House❑ Commercial ❑Trailer Court ;E] Motel ❑ Other ---------------------• ---------------. _,. ,l Number of living units:----�_--- Number of bedrooms --._.Garbage Grinder _________j_ Lot Size ---�-_�_ -----............. Water Supply: Public System arid�name -------1-- -•------------------ -;� ==--`------I----------------------------------Private Character of soil to a depth of 3 feet.; Sand❑ Silt❑ Clay .❑ Peat-E] Sandy Loam ❑ Clay Loam :❑ / Hardpan ❑ Adobe Fill Material ------------ If yes,type _________________________ {I I (Plot plan,.sliowing size of lot, location of system in relation,tarwells, buildings, etc. must be placed on reverse side.) l - NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) t PACKAGE TREATMENT f ] SEPTIC TANK:[ ] Size----------------------------------------- ------ Liquid Depth ------------------- Capacity ---------------Capacity ------ Type -------------------- Material---------------------- No. Compartments t Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line .---------_..__...._-- LEACHING LINE;}4.1�4No. of Lines ------------------------ Length of each line----_- -- ------ __------------ V ---_------ -- . ] g - ---- ---- - ------- Total Length 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------------- - Distance to nearest: Well ________________________ Foundation ______ Property Line _________.__.__._.-_____ I T SEEPAGE PIT .A' Depth i ______ Diameter _ Number _ Rock Filled Yes No Water Table Depth ------ -------------------------------------__-Rock Size.-----.------------ Distance to nearest: Well __ _______________________Foundation ____________.---- Prop. Line ---------............ REPAIR/ADDITION(P�ev. Sanitation'Permit,# -------- ---------- -�j--:------- Date ----------------------------------1 Septic Tank {Specify Requirements} _ - --------- - Dispcsal Field (Specify Requirements) -_- - --------- ---------------------- ------- ---------------------------------------------(Draw existing and req 'red addition on reverse side) I hereby certify that I have prepared this.application and that the work will be done Est 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 a work for which this permit is issued, I shall not employ any person in such manner as to beco subj ct to Wo a s ompenW ornia."' Signed ___+ L__ _ Owner - -- ---- BY ------------------------ ------------------------- --- 7itle----------------------------- --------------- (If other than owne # -•«w--•-FORIDEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- --------- --------------------- - -, DATE ....lG` Q 76.9------------------ BUILDING BUILDING PERMIT ISSUED --------------- ---------------------------DATE.a. ----'---------------------------------- i ADDITIONAL COMMENTS r ------------ ----------------------------------------- -------------------------- -------------------------------------- I ! ------------ - '---- -------------------------- -------•---- _ Final Ins ection b r - Date --o-W o �J p Y --- ------- r SAN JOAQUIN LOCAL HEALTH DISTRICT 4 E. H. 9 1-'68 Rev. 5M 4