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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT G ------ ------------------------ --------- O-� �-$--. (Complete in Triplicate) Permit No: --------- ------------------------------------ - -- �» �_- �--- y --_----_-_---- -------- ------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance Vo. 5y,nd a fisting Rules and Regulations: 4Al4 CY1 JOB ADDRESS/LOCATION - -- -:--- - -` '1- ------ --- ----- ---------CENSUS TRACT ------------------------- Owner's Name -----la/ 4$ W-/740"–>-------------------------------- ------- -------Phone '" -------------------------- CitY1 Address ............................................ Contractor's Name Jf - Q/ r-----------------------------License#�fir � Phone ? - �-� -- Installation will serve: Residence ❑ Apartment House,,[:] Commercial :❑Trailer Court i❑ Motel ❑Other - C4742,4-44 t Number of living units:--- --_ Number of bedrooms ___!,----Garbage Grinder/ -- Lot Size -------------- Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'E] Silt C] Clay ❑ Peat ❑ Sandy Loam] Clay Loam ❑ 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.) NEW INSTALLATION: lNo septic tank or seepage-pit permitted if public sewer is available within 200 feet,) TREATMENT [ ] SEPTIC TANK Size __JX--9_______----------- ------- Liquid Depth ��_------------------- PACKAGE Capacity .X019------- Type�/`��"�- Material -0 No. Compartments _'fir_______________ r le Distance to nearest: Well 449V--- � ---_________-----Foundation _, .Ile ______ Prop. Line ---—__:__------ � o LEACHING LINE No. of Lines --/----------------- Length of each line---4d--------- -_----- 'Total Length �/ _- -----_..-..---- 'D' Box ��-- Type Filter Material � 4� ter Mate Depth Fitrial,e��-_____-------------------------- t o Distance to nearest: Well __,/PQ-------_- f=oundation Z-Z7-------------- PropertyWne -SAV------------- ' Rock Filled t=Yes No 0 SEEPAGE PIT [ ] Depth -------------------- Diameter ------------__-- Number ---------------_ -- ------ ❑ Water Table Depth ----------- --------'--Rock Size ---------- Distance to nearest: Well ----------------------------------------Foundation .------------------ Prop. Line ----------.-. ------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _____---__________----------------) {t SepticTank (Specify Requirements) -------- --- -----------------------------'--------------------------------------------------------,----------------------------------------- Disposal Field {Specify Requirements) ____________ ] -------------------------------------------------------------------------------------------------------- -------------- ----------- ------------------------------------------------------- -------------------------------------- (Draw existing and required addition on reverse side) i I hereby certify that I have prepared this application,and-that!,the work will be done in accordance with San Joaquin 'i County Ordinances,j 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 the work for which this permit is issued, I shall not` �.employ"any person in such manner III � i F as to become subiec to Workman,s mpensation laws of California.n ' r � � Signed -- --- ---- - - ---------------------------------- Owner ✓"" BY = - Title (If other than owner) t F ` fOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE _. -- -2 ------ ---- --------------- I BUILDING PERMIT ISSUED .---- -;-- -------------------------------------------------------- -------------------------------- -• --DATE ADDITIONALCOMMENTS ------ ------------------------------------------------------------------- ----------------------------------------------------------------------- ----------- --------------------------------------------------------r------------------------------------------------------------------------------------------------------------------------------ --------------- r �,. --:-------------------------------'----------------------------------------.-----: '---.---------'-------------------------------------_--------------------- ----- -y- - . .. ..www..-r :.- _ --=--- ----- i p y_ ____________ Final Inspection b �_-�---------- -- -�----------------------------------------------------- -- ---------------Date - ..--- -2-- -6 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H-9 1-'68 Rev. 5M F `