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` I FQR OFFICE USE: •- " APPLICATION FOR SANITATION PERMIT Lf. ,:.... ........ .......... Permit No. 3`�7 {Complete in Triplicate) ....................:................................... 97 �� _....__...... This Permit Expires 1 Year From Date Issued Date Issued ............... .3 Y Application is hereby made to the Son Joaquin Local Health District-for a permit to construct and install the work herein described. This application is made in compliance with Co my Ordinance No. 5.49 and existing Rules and Regulations: JOB ADDRESS%LOCATION ........ ......__�I7�. .._AID .{..,. . :�1.6�.: .��ti�........ CENSUS TRACT ........... Owner's Name ......... E+Ji.a c�.. t .l -C3�5. .N........................ ..... ... --.....Phone .�6$-7ao I.. i Address �.. Z _ .._.. City ---/� �Q�- ------------- Contractor's Name ...._--. :. .:.. f p (.S_f-`- .- q-,66---- D" --r!�5............ ......License # .-- Phone .._ 6��'�1_ j ` 'u Installation will serve: Residence OfApartment House,E] Commercial [-]Trailer Court :❑ I` Motel ❑ Other .-------•-- ----•------------- ----------- I 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 + Fill Material If yes, type ......... (Plot plan, showing size of lot,. location_-of system in relation to webs, buildings, etc.- must be placed on reverse side.) (` NEW INSTALLATION: (No septic tank or seepage pit permitted if ublic sewer is available within 200 feet,) -- �� . PACKAGE TREATMENT ( ] SEPTIC TANK Size.%Xn • Liquid Depth _.._�. ........... Capacity .. . Type Vim'. ._ Material_�.� No. Compartments - ............... ' Distance to nearest: Well . --•d..----'"....---.-•r..,'.._..Foundation ..1Q_..?�........ Prop. Line ........------..--- .....� 1 LEACHING LINE j No. of lines - -. --.. ..... Leng#h of� adi'l nes--- -�- /..� Total Length _..._ .......J 'D' Box ..:�. Type Filter Material:. �4�1 .._Depth Filter Material ................ J , T :Distance to nearest: Well .._,,.: Q��.:__._ Foundation ......... Property Line ........................ , r SEEPAGE PIT Depth Rock Filled Yes No ( P - 1� -------- Diameter - ------�,^-- Number ._,-'- -- Vr- Water Table Depth ��?�_ ~ - rrZ i P .. .... . ... . .......•- •-------------•- •---Rock Size.....�...1.._._....---........_. Distance to nearest. WellY_ Distance -_._f ..�_.._ Prop. Line .eJr. ......_.. . " ` I V` REPAIR/ADDITION(Prev. Sanitation Permit# -----------... _.. ..._._.--•___-. Bate ------------------------------• - Septic Tank (Specify Requirements) ....................... - --------------- ----------- .-.........:.. I% Disposal Field (Specify Requirements) ------------------ ----------------- .... -- ----•------- ...... ------------------------- s ------------------------------ ....... --------------. ...................... ....................................... (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. Flame 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." I Signed ...... Owner By .... .. . . .. .....iTitle ---------------- ...... ---------------------------- .................. r.. of er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED DATE .. '"1. -"7-3................ BUILDING PERMIT ISSUED --------- -----• . ..... .... ...._....DATE ....-.........----.- ADDITIONAL COMMENTS .,.... ............ . ............ ........ F'4 -------------------------....................................... .. w. _......_._ ................................................................... _...... ................................................... .................... ........... ` Final Ins ection b _ _ Date :. ..1 .. .7. ................... P Y .... -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT t___E._H.---. : 1-;6$-Rev. 50-. 7/72-3:.,4