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r FOR OFFICE USE: w APPLICATION FOR SANITATION PERMIT ✓-/C ;70-- -- -------- Permit No. .. f- -` ' 3 -15- 770 W� (Complete in Triplicate) : -1 -------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is madee�in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .I- -------- fI_-------- QX-1,i e------------- ----- --------------- -----CENSUS TRACT Owner's Nameqq/�1C� �1 /__ --------------------------------------------- ----- ............Phone Address - T �� f GXfI�/1� AN------------------------------------------- City �i�� Q Sir---------------------------------- Contractor's Name - /. _._.S1 T/C_.____. ---------.License #1.7ZFT-)--- Phone Installation will will serve: Residence% Apartment House❑ Commercial ❑Trailet Court ;❑ Motel ❑Other ------------------------------------------- r Number of living units:-----f -__ Number of bedrooms c2______Garbage Grinder /. Lot Size ___________________ Water Supply: Public System and name ---------------------------------•---------------------------------------------------------------------------Private ❑ Character of soil to a depth of'3 feet: Sand'❑ Silt❑ Clay w❑ Peat ❑ Sandy Loam ❑ Clay"Loam ;❑ Hardpan ❑ AdobeiRl Fill Material ------------ If yes, type ---------------------------- � I (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) \Qt f NEW INSTALLATION: {No.septic tank or seepage pit permitted if public sewer is available within 200 feet,} ] PACKAGE TREATMENT [ SEPTIC TANK-[ ] Size---------------------------------------- Liquid Depth ____-----_-----------.----- 1 Capacity -------- > #Type -------------------- Material---------------------- No. Compartments -------------•--- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------------- ........ LEACHING LINE [ J No, of Lines ------------------------ Length of each line---------------------------- Total Length ,--________._______________- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material _.___-_____________________________-_._.._., Distance to nearest: Well _.__.____ -------------- Foundation ------------------------ Property Line __________________._:___ SEEPAGE PIT Depth __- Diameter ---------------- Number _._-___._.____--__._________ Rock Filled Yes Na R [ ] p ❑ 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance ------------------- -- ----- Distance to nearest: Well ________________________________________Foundation -------- ----------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --_-------------------------------1 Septic Tank (Specify Requirements) ------------------------------------------------P__------ Disposal Field (Specify Requirements) --------lul_w--_--- D2Tv -,-- 1-- '-__•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 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 becom sub' ct to Workman's Compensation laws of California." Signed .. -. --------- --------- ------ Owner . I By --------- --------------- -------------------------------------------------- Title -------------- ------------------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY d APPLICATION ACCEPTED BY ._. DATE -.-_I—.___.__�_ a__________________ BUILDING PERMIT ISSUED --- -- ------------------- ------------------ DATE ---------------------------------- ADDITIONAL COMMENTS --------- -------------------------------------- 3�---------------` ------ ---- _ ----- - -- -- --------------- ----------- - - -- ---- ----------- = ------------------------ = --- ------ ------ -- --- - ----- - -- ------ - - - - --------- --------------- - - ----- ----------------------------------------------------------------- ---- ------ -- - ---- ------ Final Inspection by: ----- ---------------------Date -c7 �d7-- -• ----- SAN JOAQUIN LOCAL HEALTH DISTRICT M E. H. 9 1-'68 Rev. 5M