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f FOR OFFICE USE: ---------------------- -------------------------------- --------------" y---)-1- - ---------------------- q ►PLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. _/_____.....GQ!ll_.. This Permit Expires 1 Year From Date Issued Date Issued _//__1.�`._70 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 . � ---- ------CENSUS TRACT -------------- ----- - Owner's Name -------------- --�G?�--� Phone�� 3 - �y uu Address------------------ ----d !� - -------------------------.._.__. (� ,,,, // Contractor's Name -------------- ------------------ License # _lam- ----- Phone--7---------_?60-7 Installation will serve: Residence Apartment House,❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other ------------------------------------------- Number of living units:________ Number of bedrooms ----- --- Garbage Grinder ___v___ 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 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,) 0 PACKAGE TREATMENT [] SEPTIC TANKIV c�'-ze____.,r�_x_ /_ Y _ ______________________ Liquid Depth __�_...-...__.... Capacity lk--- ----- _-- Type )+�______ Material No. Compartments ___.�....._.... Distance to nearest: Well ____Aga "_______________Foundation ----- Prop. Line ___--__-_-._._....--- LEACHING LINE X No. of Lines 3____________ Length of ach line______ --7-0-- __.______ Total Length _____ ;L-10 ........... ll 'D' Box _____ I Type Filter Material _________ _p �. ----Depth: Filter Material_______,l_�............................. Distance to nearest: Well 1_(�_''f'----------- Foundation ____ U- "Y - Property Line ________________________ `1 _ hock Filled Yes No SEEPAGE PIT �jQ Depth ___ S-_ ___ Diameter ____ __ %a-__ __________ V - - ---_ Number ------------ - L I❑ Water Table Depth ---------- ------------ ------------- -------Rock Size �11-_______ IA. -__-- Distance to nearest: Well _______________________-Foundation __0L ---- Prop. Line ...................... REPAIR/ADDITION (Prev. Sanitation Permit #____________________________________________ Date ________________________-----____-) SepticTank (Specify Requirements)-------------------------------------------------------- ------------------------- ------------------------------- ,..--------------------------- Disposal Field (Specify Requirements) ____________ ------------------------------------------------------------------------------------ - ---------------------------------------------------------------------------------- (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 become subject to Workman's Compensation laws ot'Colifornia." Signed _____ Owner BY ------ ---- r ----- -- ---- Title ------- '----------------------------------------------- "(410 ------------------------------------ "(owner 1 I 1F R. DEPAR MENT USE ONLY APPLICATION ACCEPTED BY ------ L. &E .--- -- ------ - ------------------------------------------------ DATE ---IZ 42_-__7_0 ----------- -- .c DATE ADDITIONAL COMMENTS ___________ZiBUILDING PERMIT ISSUED--------------------------------------------------------------------------------- ------------------ - 1--------� - - - ---- -------------------------------- ------------------------ Final --- -Q--- `----- -- Final Inspection by: ll ---------` --- ---- ----------- Date m 7d` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M �.-------- - --- --- .-