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FOR OFFICE USE: -------1V_ - APPLICATION' FO.R SANITATION PERMIT S Permit No: --_ (Complete in Triplicate} ----------- cc,J� ------- This Permit Expires ] Year From Date Issued Date Issued r 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 dinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION ._�, --�-��_-_ 1,; , •" '. " l � ' d7--------- --.._CENSUS TRACT Owner's Name -- _ , s t `p, / � !rll�^!le ---------- Phone r I - i = -- -- -- - Address ------ �,Y�e- ---------- ' ' ' -------=------------------------- ---------- -------- . City Contractor's Name ---------Zf-0- Q- ------------------------------------•-•- �'�' -------.License,# :_A0 �2--- phone Installation will serve: Residence 2+-*rartment House-❑ Commercial ❑Trailer Court�;[] Motel ❑Other - __.____.- Number of living units:.___ --- Number of bedrooms __-Garbage GriAder �` 3. °• a 1 3 / f -__ 1Ot $lze Water Supply: Public System and name � � r Character of soil to a depth of 3 feet: Sand❑ Silt �� i private ❑ p ❑ lay ❑ Peat F] Sandy Loam D Clay Loam ❑ { Hardpan E] Adobe-& Fill Materia! I__._.___.._ If yes, typew----- ----------------- 1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must b"e placed�,oti`reverse side.) NEW INSTALLATION: (No septicitank or seepage it , p' permitted if public sewer is available within 200 feet,)` PACKAGE TREATMENT [ 7 SEPTIC TANK �+ [ 7 Size----------------------------------- ------------s' Liquid Depth --------------- ----- Capacityr )---- ------------- TYpe ------:------------- Material---------------------- No.; Compartments --- ---------------- Distance to nearest: Well -.____'~w gp ; LEACHING LINE ' [ ] No. of Lines --- -------------------- Length of each line Foundation -----------_, --- . Pro Line - Total Length �{ D' Box Type Filter Mat rial ___________________Depth Filter Material ------- ------------------------ Distance to nearest: Well _____ __.. _ ___.__ Foundation-_.___ ' - ' ___' Property Line ` SEEPAGE PIT [ ] Depth i ------ Diameter ---------------- Number .-------------------_-------i Rock Filled Yes ❑, No Water TableDepth ___________Rock Size ---.____'.__._________-_-_�_j_ s ' Distance toInearest: Well ----------------------------- ---.•Foundation --------------------- Prop. Line /---------_---------- REPAIR/ADDITION Se Tank (Prev. Sanitation`Permit# _______.------------------------------------ ' — � Date ------ -=- ------ -1 1 (Specify Requirement) ------------ Y .. . ------- F — ----------= ...._ Disposal Field (Specify Requirements) -- _ - _ __-_ � � ` ----------------------- + ; _ -----------------------___________________ _______I .. 4 _--.___-_________-_____ ._ _ _ _ _ _r____-„.____________________ __________ ___ _i(,raw existing and required addition on reverse side) i I hereby certify that I have prepared this application and that the work will be ldone in alcordancis with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hf me owner or licen- sed agents signature certifies the follo4wing: I certify that in the performance of he work for which this permit is issued, ['shall;not employ any person in such manner as to become subject to Workman's ompensation laws of California.” '" w v �.� Signed ------------- - Owner ------------------------------------ --------- Bya----------------------•-------------------R- Title --------- other than owner) '{i ------------------------------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY BUILDING PERMIT ISED - __ - --- --------- --------------------- ----- ---------- ----------------. DATE ------^ r� ----------------- SU - -------- �- = e- ----- -- ------- ---- --- ------ - - -'----- ----------- ------ -°- ADDITIONAL COMMENTS --------------------- - ----------- --------- ---DATE -..---------- t --- t --------- ' ------------------------------ -- ----------------------------.------------- ------------------------------------------------- -------------------------------- ----------------------------- - Final inspection by: --_ _. ------------------ ( Date _��r.�� - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ;