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FOR OFFICE USE: .. — r r APPLICATION FOR SANITATION .PERMIT ---------- ----- `�� 4Complete in Triplicate) Permit No.. .'.i Date Issued ----------------- -- --- ---------- -:-----_ ; is Pe",* res l Year From Date Issued Application is hereby made to the S 7_4�154i;n uiLoca ea{fFa�Di 'irict for a permit to construct and install the work herein described. This application is made in cc itCounty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION __r 1�p i - �/' -�lys' �C A SUS TRACT --------------__________ Owner's Name ---- ----- ¢ ------------------------------------------------------------ -----Phone ------------------------------------ Address -------------------------------- -Address --------------------= t3-s:----- r- --- lel_ ---------- -----------------• City --S°1'--------------------------------------------------------- Contractor's Name -_ '•---- eier_ _;-------------------------------------------------------------License # 271 - -- --- Phone _ G_ '----------- . Installation will serve: Residence . partment H,ouse,❑ Commercial ❑Trailer Court i❑ Motel ❑ Other --------=------------------------------------ Number of living units:--------- Number of bedrooms ______Garbage Grinder -+ ___ Lot Size �_______________ Water Supply:.Public System and name ___ -------- l�J _ --------------------------- ---------------------- Private ❑ Character of soil to a depth of 3 feet: Sand-❑ It:❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loam.E] Hardpan ❑ Adobe„ rill Material,V._____ If yes, type ____________________________ (Plot plan, showing size of lot, location of.`.system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit pe'mitted if public sewer is available within d200 Deptht)__ PACKAGE TREATMENT [ ] SEPTIC TANK ] ze------ Capacity -� Type --� II � �. �� Material hC/1 No. Compartments Distance to nearest: Well _ ____// ___________________Foundation ---------- Prop. Line ---:��2--------- LEACHING LINE [ No. of Lines _____ f `-__ Length of each line---- ,!_�i ------- Total Length �_�______________f Yp r ` D' Sox T }e Filter Mat griai J 7-6 Filter Material ____.______ _________ Foundation 49- Property Line _��_______ Of Distant to nearest: Well __ `/ SEEPAGE PIT �,y Depth c Diameter .3__.___--_ Number --------,;L _________ Rock Filled Yes �No ,i❑ �t11'' l - Water Table Depth _--f_--_ a --,;-------------------------Rock Size _- _/_ - - - ___-- --- / Distance to nearest: Well ___/�- _-'------_------------Foundation -____ ---- Prop. Line •�- __._.____ REPAIR/ADDITION(Prev. Sanitation Permit# --------------------- ------ ---------------- Date ______-___________________________} Septic Tank {Specify Requirements) ----------------------- '-------------------------------------------------------- Disposal Field (Specify Requirements) ---------- ---------------------------------------------------------------------------------- --------------------- ------------------------------------------ ------------------------------------------------------------------=---------- ------------------------------------------------------------------------------------------------------ (Draw existing and required addition on reverse side) 1 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 Son 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 subject to Workman's Compensation laws of California." Signed -------- ------ ----- = Owner , ` = Title ... --- �l By ------------------------- ----- ---------------------- f (If other than w er) 4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . - - --------------------------- ------ ----- DATE /I 3 --------------- BUILDING PERMIT ISSUED ----------------------------- -----DATE ---------------------------------_ ADDITIONALCOMMENTS -- ---------- -------------1---------------------- ---------------------------------------------------------------- ------------------------------------------ ----------------- ------------ -------- ---------------------------------= ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- ------------------------ -------------------------- p -------------------------------------------- ------------------------------------------ -- Final Inspection,by, --- --- --------------------- ---------------------------------------------------------------------------Date � c� -- -�------------� t�-4-1 d -------- JOA SAN UIN LOCAL HEALTH DISTRICT � Q E- I••I. 9 1-'68 Rev_ 5M " . r