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FOR OFFICE USE:r�,'_3a APPLICATION FOR SANITATION PERMIT `� 7- _70- - 1- Permit No. (Complete in Triplicate) ------ ----- =----- This Permit Expires 1 Year From Date Issued Date Issued la 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 �Ordinna-'n-ce No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ------------- _-- -----C�Gti _Q�-'----------------------CENSUS TRACT -------------------------- 7� ----.--Phone Owner's Name -------- ------fa-t, --- ------ = Address --------------{��- ------------ -- --•---- --- - - -- ----------- --. City ------------------------------------------------ Contractor's Name ---------- ---------------------?` - License #AV -------- PhoneV4.li--Y�D•7--- Installation will serve: 7Residenc��er artmterrt I louse Commercial ❑Trailer Court i❑ � p ❑ Motel ❑Other ------------------------------------------- Number of living units:----/------ Number of bedrooms __!--...Garbage Grinder ------------ Lot Size ---y3tA-___4UA14_Z ........... 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 (X Fill Material ------------ If yes,type _______-________________ (Plot pla( 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,) PACKAGE TREATMENT [ ) SEPTIC TANK. ) Size--------- -------------------, ------------------ Liquid Depth ----------------_----_- Capacity ___ _______________ _Capacity -------------------- Type -------------------- Maiterial--- -`. ------ No. Compartments _.-------------------- Distance to nearest: Well __________________________ _______Founda'tion ______ ------------ Prop. Line ...................... , . LEACHING LINE [ ) No. of Lines -------------------- Length of eachl 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 ❑ No 0 Water Table Depth ------ - Rock ize Distance to nearest: Well----------------------------------------Fo(indation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -_------------- - --_--- _- ---_-___:_ Date;_______ ________________) Septic Tank (Specify Requirements) ------------- ----------- ----- -- Disposal Field (Specify Requirements) ---.,_-al4.d.f�►---------�6------ --------------- -------- --- ---------- ------ ---------i�--------- x-6-XIO-'--- - t --------------------I--- -- . --- ----------------------------------------------------------------------------------------------------------------------------------------------- _ '(Draw existing and required addition on reverse side) I hereby certify that I have ifrepared 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 --r---- 0----------------------------------- Title ---------'------------- -------------------------------------- (If oth an owner) 79, FOR DEPARThWNT USE-ONLY APPLICATION ACCEPTED BY _ ,--------------------------------------- DATE BUILDINGPERMIT ISSUED --------------------------------- ------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------- ------------------- --------------------------- ------------------ �- �•-a------_3w_ ------------------------------------------------------------------- --------------------------------------------------- ------------------------------------------ - - Final Inspection by: f Date —.z SAN JOAQUIN LOCAL HEALTH DISTRICTjl, E. H. 9 1-'68 Rev. 5M