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*� Q FOR OFFICE 1.ac: r?' APPLICATION FOR SANITATION PERMIT Permit No. --------------__-----. �} _ (complete in Triplicate) ................ __fi,-- - -------------------- This Permit Expires I Year From pate Issued Date Issued _.73. 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 .__! �__ _ _ C� l_____ ��_I____.. TRACT 5:75D---- Owner's Name Mlts----/,�,?gbel _- i7----•----------------- ----------------- -------Phone ------------------------------------ Address j !7T// l�'� City _ l� U/�3--- ------------------------------------------ n X Name -___ -a �_..�1�_C '/1_` Q---------- ---------------------License # _7_ l— Phone �`3 `- ---------------- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- _ Number of living units_____________ Number of bedrooms ___________Garbage Grinder ------------ Lot Size _ __- �` e ____________-__ Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand,�5 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,) PACKAGE TREATMENT f ] SEPTIC TANK:[ ] Size------------------------ ----------------------- Liquid Depth ---------------------.----- F Capacity -------------------- Type -------------- Material----- ---------------- No. Compartments -_- -_-- Distance to nearest: Well _____________ ;______F ndation _.-------------------- Prop. Line ----.__-____-_________ LEACHING LINE; [ j No. of Lines _____________ /te g ----- nt of each" line ------------- Total Length -----------------------•__-- 'D' Box ------------ Type Filte al ------------------ -Depth Filter Material ----------------------------- -------------- Distance to nearest: Wel _____________ Foun tion ------------------------ Property Line __________________-...__ 4 SEEPAGE PIT [ ] Depth ___________________ Dia ______________-_ Nu bar _;______________-----------_ Rock Filled Yes ❑ No i❑Water Table Depth ------- --------------------- --------Rock Size -------------------------•- Distance to nearest: Well ___________________ ___ _____Foundation __________________ Prop. Line ______________________REPAIR/ADDITION(Prev. Sanitation Permit�# ------ -- -------------- ------- Date ----------------------------------) SepticTank (Specify Requirements) --------------------------------------------------------- ----------------- ---------------------------------,----------------------------- Disposal Field (Specify Requirements) --1/l�4ra-�A�/__/ 049/x9 -__- e Q _______________ D _Ff fvd� _ -ra- ------F' 1 "7^��' nrd-.r. r � -----0"Y------ ----- ___---___-_-se-- -_-_-----_ ----------------------------------- (brawexisting 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 Wo kman's Compensation laws of California." Signed --- - ---•---- -- ------ - ------------------------- ----- ----- Owner ------------------------ By ------- --- ---- --- -- - ---- ------------------------ Title ------------------------ ---------------------------- --- other than owner) � FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------!- _- R -------------- DATE -----.„5 _Z--- BUILDINGPERMIT ISSUED -------------------------------------- -------------------------------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS -------------------------------------- ----- ---------- -----------------------------------------------------=--------------------------- -------------------------------------- ---------------- - ------------------------------------------------------------------------------------------ ----------------------------------- - ------------------------ -- ------------ --- ------------------------------ ------------ -------------------- - - ----- --- ------------------------------------- -------- ------------------ - ----------- ,--- -------- ----- - ----- --- Final Inspection by: -------- - --- --------------------------Date --- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M