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)k q 5� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------;-------------------------- 3—1J'Sl -------------------- (Complete in Triplicate) Permit No. __7____._________._. ------ ----- - ___ is Permit Expires 1 Year From Date Issued Date Issued __174 'r7-3 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/LO TION �__�1 --------- G: �_a _'_r _�_ C� =----------CENSUS TRACT --.----------------..-._- a , Owner's Name ----- -1--vr------ ---i-"'--c-�--�-'--- ----------------------------------------------------------- -------------------Phone ---------------------- -------------- - _ .- Cit C --- ----.------ Address --__--_-_-_- _ q�, - --- - - - - ---•--------------- Contractor's Name - `�' License # 7�5. 5 Phoned /�--- Installation will serve: Residence partment House❑ Commercial :❑Trailer Court !❑ Motel ❑Other ----------------------------- ------------- Number of living units:-___ _____ Number of b drooms __-_ _-___Garbage Grinder _ Lot Size _ __ _�_� _________________ Ek Water Supply: Public System and name ___-i __.__ � i____________5/--------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat E] Sandy Loam ❑ Clay Loam E]Hardpan E] 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.) "t NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK:[+— Size______ _:: _. ` q p � �` ----------------- Liquid De th -/ Capacity ___„__ Type Material -!? Sr _ No. Compartments 7�— Distance to nearest: Well ---, -'_14______________________Foundation ---0!------------ Prop. Line __._-:__-_---- LEACHING LINE [L)'__No. of Lines :_t�----____________ Length L_.J ach line_v�_��__--_____ Total Len thr._l_�p�-------------- 'D' Box __'_ Type Filter Material-- -- aterial J- _ _ ____ _Depth Filter Material ___ 1 ............................... Distance tlarest: Well ____ ---_____ Foundation ------- _________ Property Line __ �.............. SEEPAGE PIT Depth _, -------,__ Diameter __�_a l____ Number ___�- _____________- Rock Filled Yes '2--"WO Cl Water Table Depth --------1 -------------------------------Rock Size ------------ Distance to nearest: Well ---_/)l-/tO---_____________________Foundation ------IzA-�'_l------ Prop. Line _.. ............ REPAIR/ADDITION(Prev. Sanitation Permit# __________ _______________________________ Date ________-_______.-.________._____) SepticTank (Specify Requirements) ------------------- -------------------------------------------------------------- ------------------•---•----•----------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ --------------------------------------------------------------==------------------------------------•--------------------------------------- ----------------------------------------------------- (Draw existing and required addition on reverse side) 1 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 of California.” Signed -------------------------------------------- - ----- ------------------------------------ Owner BY ------------------------------------------------- - — > -----Title -------(!IC ��` `'�/ (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY C%_,_ _ ----___________ <� DATE _ ___ �_ ______ BUILDING PERMIT ISSUED --- --------------------------------------------- ------------------------------DATE ------------- ----------------------------- ADDITIONALCOMMENTS --------------------------------------------------- -------------------------------------------------------------------------------------------------------- :: tk = --- ; :::::::::_______:::::::::::::::::_________::::::::::::::::::::::::::________________::_____::::::::::::::::::::::::::::::::_::::::::::::::::: :::: ---- - Final Inspection by: ___ Dateor SAN JOAQUIN LOCAL HEALTH. DISTRICT E. H. 9 1-'68 Rev. 5M