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FOR OFFICE USE: �Ap �ICATION FOR SANITATION PERMIT n�� v ------- ---- ----------- -- -- r Permit No: _ -- (Complete in Triplicate) ------- -=-------------------------------------------- ---------------------------------------------------------- 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 No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION .---------Qa a_�-------��:--- ( k�__ `�__ -.-----CENSUS TRACT -------- Owner's Name -------- F'ran16 L-----92-ye-5------------------------------------- ._Phone S 3'S^(ALQVJ-'/-------=- Address --------------------- &XIM--'e------------------------------------------------------------- City ------ ---------------------------------------•---•------ - Contractor's Name ------------ ------ J---------------------------------------------License # : ---- Phone -------------------.::-----= Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other -------- ----------------------------------- f� f 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'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe A 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] �/ PACKAGE TREATMENT [ ] SEPTIC TANK[ f• -SQize_-____-____/4200. _______•__ Liquid Depth ---- /r7�r�____.----- pr Capacity -------- 19400______ Type (in-CIA,--- Material_.:_____ -. No. Compartments ___SX______________ U Distance to nearest: Well ____-_�0_____________•________Foundation ......?b---------- Prop. Line ___C�y_;_______-.__ LEACHING LINE [ ] No. of Lines -----3-------------- Length of each line-------VC>------------- Total Length�� y- -__.......__ � � 'D' Box _.' .-- Type Filter Material �_ __Depth Filter Material _--____.(g_ ----------------- _--------- Distance fornearest:-Wei l-""7jD_-"T___'Foundafi on ____________ ___________ Property Line __76-7.__-__-_-___ 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 ----------------_-----------------) SepticTank (Specify Requirements) -----------------------------------------------------------------------------------------------------------..__,..--------------------------- Disposal Field (Specify Requirements) --------------------------------------------------------------------- ------------------------------------------ ------------------- ti ------------•------------------- ----------------------------------------------------------------------------------------------- +. (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 j County Ordinances, 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 ' the performance of the work for which this permit is issued, I shall not employ any person in such manner i as to bec e s biect to Workman's Compensation laws of California." Signed ---------- -------------------------------------------------- Owner By --------- --.Jell -------------------------------------------------------- Title ----- -- ---------------------------------- ------------------------ o r th owner) FOR DEPARTMENT ONL APPLICATION ACCEPTED 8Y - - -- - -- - DATE yYJ BUILDING PERMIT ISSUED ------------ /------------------- DATE ------------------------- ----------- ADDITIONALCOMMENTS ------------------------------------- -- ---------------------- ----------------------------------------------------- --------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------- --- - ------ ---------------------j Final Inspection by- ---------------------------------------------------- Date � ��{ T SAN JOAQU L AL HE RIOT E. H. 9 1-'68 Rev. 5M �•- .