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r � FOR OFFICE USE: N APPLICAY�iON NOR SANITATION PERMIT 3 o--o Permit No: :--7-- ------------- (Complete in Triplicate) Date Issued This Permit Expires 1 Year From 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: PPnn ff --U�-`T "--- JOB ADDRESS/LOCATION -- -------- -------- --------------------------------------. CENSUS TRACT u--------------•----------- Owner's Name -----------�'? GC.X1 --------------- -------------------------------------------Phone. 1--` ------ Address - ------ 1 { -------� -------------------- City ---------------------------------------------------------- ------ Contractor's Name --------- -- ---------------` :License # _l_W.j�71------ Phone ..... Installation will serve: ResidencevApartment House❑ Comrriercidl:❑Trailer Court i❑ i Motel ❑ Other -------------------------------------------- �-- k �.. Number of living units:----I-r----__ Number-ofsbedrooms __7�arbage Grinder --------- /- Lot Size �________0----K-- - }------- [' ----------------Private ❑ Water Supply: Public System and name ----------------------------------------------------------------- -------- Character of soil to a depth of 3 feet: Sand'❑ Silt 0 Clay ❑ Peat-E] Sandy Loam ❑ Clay Loam ❑ Hardpan E] Adobe Fill Materia I ''------ If yes, type ---------------------------- i (Pilot 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_pyblic sewer is available within 200 feet,) PACKAGE TREATMENT f ] SEPTIC TANK'[ ] Id Size------------------------------------------------ Liquid Depth ---------------..--------- � Capacity -------------------- Type ---------- Material----------------- ---- No. Compartments -----------------•---- Distance to nearest: Well _r-______:_-__--------------------Foundation ------ Prop. Line ___________--.-.---_-- LEACHING LINE ( ] No. of Lines ------------------------ Length of each line---------------------------- Total Length -------------------_-----•- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- Distance to nearest: Well -------------------- --- Foundation ------------------------ Property Line I 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 ----_______________________ Septic Tank (Specify Requirements) ------------- = ------- _ =---------- = -----•--------------------------- -------------------------•- , Q � ;----- Disposal Field (Specify Requirements] �Z ` --- --- --------- - ---6---3-3 �---------- - --- ------ - --- -- -------------------------- ------------- ---------- F ____________ _______________________________________________________________________________________________ _______________________________________ _ __._--.-____.______._________---__---___ (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 JoaquinAocai 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 ------------------------------ -------------- By --------- - - - -------------- - --------- - - (If than owner] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------•--------------------------------------- DATE '3. -.7- 7-75------------------ BUILDING PERMIT ISSUED ---------- DATE ' ADDITIONAL COMMENTS ----------------------------------------------------------------------------- -------------------- -------------------------- - - " - -------------------- ----------------------------------------------------------- --- -=--ti- ------------------------------------------------------------------ --------- ----- = A ' 3 '—'------------------------------------------------------------- ----- - ------------------ ------------------------------- -------- - - ---- ---- Final - ----- Final Inspection by- --- Date SAN JOAQUIN LOCAL HEALTH DISTRICT G � E. H. 9 1-'68 Rev. 5M