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FOR OFFIC USE: •' -76 - �� APPLICATION FflR SANITATION PERMIT �� rte_- %_/a-y --- ----------------- Perm t No. -- - --- (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. JOB ADDRESS/LOCATION . Q -S�''- ----- NCS----------------------CENSUS TRACT -------------- ----------- Owner's Name ---------1-=/A�--------04_ CA----�XTQ - - Phone !/77--7 e_ Address ------ p_ ------------- ---- City - -- v�� 1�-TT©!/ Contractor's Name ---CE1R-'T_,_F--_l_E ------------- ?_ _1Q_4-_-_-_l_W.License # �� - --�3- Phone Installation will serve: Residence;KApartrryent House(] Commercial ❑Trailet-Court Motel ❑Other----I'.A-0A tA:$___________________ Number of living units:_______ Number oft bedrooms ______--__Garbage Grinder -______f_.�,Lot.Size ___l!?0 --_----- C9.4-}--__- Water Supply: Public System and name ___ ,�}L_i_t'_r_-_____ __IhT _-------1 t :---- ,-------------- ''._..Private ❑ Character of soil to a depth of 3 feet: j Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay L6am Hprdpan ❑ Adobe JK 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.) U4 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,): PACKAGE TREATMENT [ I SEPTIC T�NK f ] Size------------------------------------------------ Liquid Depth __ __-_-____.-.--_--- -- Capacity ------•------------- Type -------------------- Material--------------------- No. Compartments ------------ Distance to nearest: Well ---------------------------- -------Foundation ___________________ Prop. Line ...................... LEACHING LINE `� No. of Lines '.________'_ g 5� ___ Total Le ,___ - Length of each line - t�9th o 'D' Box __Z. ___ Type Filter Material ___IMIKDepth Filter Material ------_«_----------ICS#................ Distance to nearest: Well _A197/4C----- Foundation ------I_( ------------ Property Line ------ ........... SEEPAGE PIT Depth ----- ---- Diameter ___ ~___ Number ------------)-------------- Rock Filled Yes No Water Table Depth _______________&S--i-----.-----------------Rock Size ------ L� _ �-- ---------------- Distance to nearest: Well ----)4QN6___________________Foundation ____-_�0-a_--___ Prop. Line __.�........._... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) ------------------- -------------------------------------------------------------1•------------------------- --------------------------- Disposal Field (Specify Requirements) ---•-- co----------- �----------�=X'-LS'T� � C--------�`� 6 ------------ -- t-.5----- �N� T-� T �°� ✓ �� r--------i-.S C Y T ---- �"w s o ( raw ex ingreq fired addition on reverse side) 1 hereliy 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 of California." Signed ------- ---------------- -- ------ Owner ------ ----- BY - ^"!E. ---- ..�1.,�---------- Title - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --- - --- ---- - ------------------------------------------- DATE ---- = _/57------ BUILDINGPERMIT ISSUED -------------------------------- --------------------------- --------------DATE ------------------------------------------- ADDITIONAL COMMENTS -------- - - - - -- ---- - ------- - --------------- --- --- -- -ff- - ------------ ------ ---- ,- - --------- ----------- Final Inspection by: ---- --------------------------------------Date -------�-------�-/- --Y----------------��---- ------ - --- �-- -•----r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M