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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. __-�. -G,--�.�-� � --------------------- - ----- (Complete in Triplicate) Oj�j G� G ._ -- 1W -I--------- ---- ----------- ------------------ WX p Date Issued This Permit Expires 1 Year From bale Issued 0 /}u Application is hereby made to the San Joaquin Local Health District for a permit to construct install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .--- a-- . _ .r 9 -------------CENSUS TRACT ------------------------ �� ry _ Phone ----------•�_---------- Owner's Name n �.✓ y t __ _ __________________________ 6 . .. �, Cit _________�•_:._*� _____________ Address ------------ --------- -- --•'-----`-'�-�------- ------;;-- ---------------------•---� _ Phone .---_� -- - -- Contractor's Name ------ -----_-------'-' _:-_"----------------- ---- -------------------------License # -------�--- - -•-•---••-- Installation will serve: - Residence -ApartmenfHouse❑ Com mercial-:❑Trailet Court-,[] -- :. � Motel,[.]"Other .-------¢�-'=----^�,-----------•-- - �- Lot Size -------�.� ---------------------------- Number ------- -- - �_.___9'&. _. ----------- Number of livingunits:_-___ ______ Number of bedrooms _4 __ ____Gaba e'Grinder ::__ Water Supply: Public System and name -- ---- -------- ---.--------_- --------------------------------------------•- Private 14 Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom[] Hardpan ❑ Adobe Z Fill Material ----r _ - 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 permitted if public sewer is available within 200'.feet,) \ PACKAGE TREATMENT f I SEPTIC TANK''[ f _Size--------------j- r , " Liquid Depth ------- ---------.----- .. i:Mti Material No. Compartments ------ �` Capacity ---I- --- --- Type Distance to nearest;--Well-------- ' =i------ ---•--Foundation ------)k'le----------- Prop. Line -----------=-------- Tot LEACHING LINE [ ] No. of Lines Wit,___ -.-=� Length of a eachilineDe th Filter Mater alal Length ------ - --------------•-- ' il f. " _____________ "D" Box -r _ __ _ Type Filter Material P '---� ------- Foundation ------------------ --- Property Lin_'-_-------- -_--- tWel! -•------ Distance to nedres : :":___ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No .i❑ Water Table Depth ------------- ----------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------foundation -------------------- Prop. Line --------------- ...... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------=-=- ------------1 Septic Tank (Specify Requirements) -------------------- ----- --------------------------'-------- ----------------------I ---,._---"---------------------•- 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 Ordinancesr 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 as to become subject to Workman's.Compensation laws of California." Signed - ----------------------------------------- - -------------------------------------------- Owner i �t _ _t!_ Title ---------------------------------------------------------------------- j AO- (If other than owner) FOR DEPARTMENT USE ONLY DATE _ ---- l �',', { = ` APPLICATIONACCEPTED BY --"---._---=- ------------------------------------------------------••-•--- ------------------ --- BUILDING PERMIT ISSUED - :r---- -------- ----------------------- -------- -------------------------------=----- -------DATE ----------------• --------- - - ADDITIONAL COMMENTS -------------------------- --------------------------------------------------- ____________________________ ________ ------------ ------------------------------------ -4_ fR.- ___ ____._ _.__.____._____________________________________ _ ------_____ ___..______._.__-___.___ ___--___ - .7 Final Inspection by: ------------------------- 'Date --- 1A SAN JOAQUINCALF HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M•