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FOR OFFICE USE: Wthe�an PPLICATION FOR SANITATION PERMIT - --------------�--------- ----------------- Permit No, (Complete in Triplicate) ------ -------------------- ------------------------------- This Permit Expires ] Year From Date Issued Date lssued ---�_,_._.7/ Application is hereby madquin 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/LOCATION .__. _U L_.G._ - ----- i ---------------------CENSUS TRACT + Owner's Name /-�f-.5C-1-44 ��- �/-V/ ��----------- ---�-- •-------------- ---Phone2c17,.�e.`Z3---27 Address _ a-1 - I`, City 11rI------------•------ Contractor's Name --------I-----------••-------------------------=---------------------------------------License #-------- ----------------- Phone --------------•------•-------- r Installation will serve: Residence []Apartment Houseg'Commercial bZTrailer Court i❑ Motel ❑Other Number of living units------------- Number of bedrooms ___________Garbage Grinder ------------ Lot Size -------------------------------------------- Water Supply: Public System and name -_ ___ k pp Y Y --------------------------•-----------------------------------------------------------------------.-----Private ❑ G Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam '❑ Clay Loam X V Hardpan ❑ Adobe '❑ 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 side.) �1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} if PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size_______________________.______________________ Liquid Depth ____. ______:.___,____. k Capacity _ Type Prtc_A61____ Material-CO"C _ele No. Compartments Z`_..... r ---------------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---- ----------------- LEACHING LINE [ ] No, of Lines ____ __ --- --------_.____ Length of each line______-8�_____________ Total Length��___ ..__.,_ 'D' Box ---/_------ Type Filter Material RO�_k______Depth Filt5 Material ------C_0__.________ j-- ------ Distance to nearest: Well /_0_a__-_-_______ Foundation ___l�_________ Property Line - ______________ SEEPAGE PIT Depth ________________ ___ Diameter e r f_____ Number _-._ ----------------------- Rock Filled Yes ❑ No 0 Water Table Depth ----------------------------------- - _ _-------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) 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 Rules and Regulations of the. San Joaquin local Health District. Horne owner or licen- sed agents signature certifies the following: f "I certify that in the performance of the worts for which this permit is issued, I shall not employ any person in such manner as to become subject to orkman's pensation laws of California." Signed -_� , ---' ---- --- ---- ------------------------------------------ Owner BY --------------- - ------------------------------------------------------'-------------- -------- Title -------------------------------- ------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------ --- -------�--- ------- :�X------------------------------------------------------ DATE 71,2, 71 ;7 r BUILDING PERMIT ISSUED : - DATE ------------------------------------- - ADDITIONAL COMMENTS -------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- -------------------------- ------ ------------------------ - - - -- - - ---------- ----------------------- Date --Final Inspection by: A --------------------------------------------------- ` - 4 � SAN JOAQUIN LOCALTH DISTRICT S ' - E. H. 9 , 1-'68 Rev. 5M ;