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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT , .................••• , Permit No. .7,y',..... I (Complete in Triplicate) --------- ........................... ....... � This Permit Expires 1 Year From Date Issued Date Issued __.--"....:........ Application is hereby made to the Son 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 Regulationsr .......: ...:.. JOB ADDRESS/LOC ON . ..�_� ._.. .._.. . . .�_t.[�!�--��................................. CENSUS TRACT ...... ..... ..... Owner's Name C_r1.�.�.�._.0 Phone __ . �V Address ............S._car".C........-------..... .:........ :'• --•---... ......... ............ City ......7_76r� :....:.....:_._........ ....... .,>. . �... , ....r .. License# Phone .......:. Contractor's Name �... .. . P -- .........:............ --------------•.... Installation will serve: y Residence 0 Apartment House C❑ Commercial❑Trailer.Court a - R Motel Qther __.e k r`........... Number of living units_____________ _Number of bedroo s,------------Garbage Grinder ------------ Lot Size ......__._._...__._.....________.......... . II Water Supply: Public System and name _.. .a.f_�...�.....111J_a? •.-------------------------------------------•--.................Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material ....... If If yes;type ____________________________ y (Plot plan, showing size of lot, location: of. system in relation to wells, buildings, etc. must be placed on reverse. side.11 NEVINSTALLATION: (No,septic tank'or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ J ''SEPTIC JTANK / Size........................._..............•-------- Liquid Depth ......._._._•_-•_• -:_ Capacity ._�#?QQ._ .a�. Type .................... Material_ C/' / No. Compartments ......�... ...__ F F r� Distance to. nearest: Well _Foundation 104 f .-. Prop. Line -S d --• ... ....... LEACHING LINT: No. of Lines Len th of each line...... . �d Total Length. ........ ..,. � [ ....__... g �. µ 'D' Box ----- Type Filter Material ... .-- .. .Depth Filter Material ------ l ..._ ..__. T +. Distance to!nearest: .Well --- - -=-------•-----..... Foundation .G� .---:.:_: Property Line ._.:.��. .. .:..:. .... SEEPAGE PIT [rj! Depth _.. 7-. Diameter1. 333_.,..... Number .._ .......... Rock Filled •Yes -No ❑ G ( Water Table Depth .... ...... ................................Rock Size .................................. Distance to nearest: Well :.......:.................................Foundation Prop. tine r f� REPAIR/ADDITION(Prey. Sanitation Permit# _.. 49..�. --------------- Date .................................. SepticTank (Specify Requirements) ..........___..............--.-------&-----•................. ..........................- _ .........................-..... _ a n J-1, Disposal Field (Specify Requirements) ........-•-•--.._...--•••---...•----•---•-------------------------•..............-•-----------• •-•---•---•- J --------------------------------------------------------------------•------------••------•---------------------------------------------------------- ........................ (D raw ------------------------ ----------------..._ . -- - (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'Rule and Regulations of the San Joaquin Local Health District. Home owner or Iicen. . sed agents signature certifies the following: "I certify that-.In the performance.of�tha.work_.for which..this-permit-is_issuedi-I-shall-not employ any person In such manner as to bec a sub' ct to Workman's Compensation--laws of California." " Signed . ! _ Owner By ...... ---------- ---------------------•----•---•-- .....................................•-------------- Title ...... (if other than owner) _ ,.� FOR DEPARTMENT USE ONLY +. APPLICATION ACCEPTED BY _.... -.. .. .. TM :..:.. DATE ..... :. ..�_ _.. _. _.... .._. :--- . - �- BUILDING PERMIT ISSUED ---------------;--- - ---....--------.......-•----•--------------•----------------........:......-=-.....DATE ........................................... - ADDITIONAL COMMENTS .._:.....-•---•!.............................. f '- - ----- -- --- ---- -- •.----- •----- _ .. .... • ......_. - Final Inspection by.. = •................ Date ..... . ..":. .�.� SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H.13 24 1-'68 Rev. 5M 7/ 2 3 M