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1FQR OF iCE USE: r APPLICATION FOR SANITATION PERMIT G cw— Permit No. _7t'-_ �--p [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.. 5x49 and existing Rules and Regulations: JOB ADDRESS/LOCATION : - �' � ev �� f=� __.°,�' ----:-- "---CENSUS TRACT -------------------••----- `r --------------•---- Owner's Name _.�y�- - �---�Fl-� d�'��--•�---------- - ------------ ---------:------Phone ,- ----------- Address � �► 9 / ' City -1-7 (!r'� Contractor's Name � ..°�-��r �--------------- - ------.License #� � - Phone Installation will serve: Residence/VA partment House'❑ Commercial ❑Trailer Court ',❑ Motel ❑ Other -------------------------------------------- �• Number of living units:- ______ Number of bedr oms __2-r_---Garbage Grinder�,�__ Lot Size�Go-�X ------- -------- ame Supply: Public System and name L:. 1-- � � s Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe 'X Fill Material ------------ If yes,type ---------------------------- (P].ot _______________.___---____{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,) O PACKAGE TREATMENT [ ] SEPTIC TANK'( ] Size-------------------------- - ------------------- Liquid Depth -------------------------- 10 a Capacity ------------:------ Type -------------------- Material--------------------3- No. Compartments ------ --------------- ` Distance to nearest Well ------------------------------------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 ------------------.----- SEEPAGE PIT [ ) ` Depth ------.__._ ° Rock Filled Yes No s Diameter Number --- ❑ 0 .•Water+Table. Depth --------------------------------------------------Rock ---------- ----- ---- --------Rock Size -------------------------------- -, Distance to nearest Well`_y--_��_t_ ---------------------------Foundation -------------------- Prop. Line --------------------- rj ) , REPAIR/ADDITION(Prev. Sanitation Permit.#}-------------------------------------------- Date ________________-------------_""--) Septic Tank (Specify Requirements) -- = ------------------------------------- - ,r - Disposal Field (Specify RequirementsL' _ � -------� '•""""" r _____________ (Draw existing and required addi#�o n reverse side) I hereby certify that I have prepared this application and tkat the- work will be done in-accordance with San Joaquin County Ordinances, State Laws, and Rules gnfl 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 wor� for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Comb *tion laws of California." ,01, Signed --- --- - ------- t --I---------- Owner x --- ----- �a , By ------- - --------- -'---�-=r------------------ Title .-- ---------- ---------------------------- t; (If r than owner) ) ` ' " , I. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �'T^,� .------ ------------------------------ :� DATE 7/ ------ -- BUILDINGPERMIT ISSUED ----------------------------------'---------------------------------------------- ADDITIONAL --------------------- r f� DAT) _..--- ADDITIONAL COMMENTS --------------------------- - ----------------- ---------- ------=--------------------------- a..� IL--------------------------------------------------- ------------ - --------------------------- -- --------------------------- 1 ---- ---- ------------------------------------ = f ------ ---------------------------------- - ---- -------------------------------- - ----- -------- --- ----------------- f #' Final Inspection by: ---------- --- [-- - --- -- ------------------------------------------ 5 ---------------- -------------------- Date �� SAN JOAQUIN LOCAL HEALTH DISTRICTy/ E. H. 9 1-'68 Rev. 5M t ,M; °� _s V% + ,