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R OFFICE USE: APPLICATION-fOR SANITATION PERMIT --------------- -- - J fi (ComFlete in Triplicate) Permit No. _7l ----- ------- ------------------ ------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Iss d -------------------- - 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. 54Z&HNSU1S 49 and existing Rules and Regulations: JOB ADDRESS/LOCATION . �� --------GZ-------ev TRACT Owner's Name "-t _- ----- Phone 07---- G --------------------------------------- Address °" l -------- --- ------- - ------ - ----- City Contractor's Name ------- K� - %f" ------.License # --------------------- _A4 -•�'�°� Phone - - v .s' � Installation will serve: Residence ,2q House❑ Commercial [-]Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:_____,_ Number of bed oms ____,3-__Garbage Grinder�e--- Lot Size _ ____�__L__a_1f_�_- Water Supply: Public System and name ______-- 11.5�1�-- ------------•------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe'Df Fill Material ------------ If yes,type ---------------------------- (Plot _________________________(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 [ ] SEPTIC TANK� Size_- __ Xf -------- Liquid Depth ____�_______________ (_ Capacity102012'_64VTypeAteeMaterial.__& No. `Compartments -----�_......... _t /' 6— r Distance to nearest: Well __ QW6 _� - '_ __Ze Foundation ------ ��_________ Prop. Line __,___�_____________ LEACHING LINE No. of Lines _____ ______________ Length of each line-_ _�_____ Total Length A-� '� '` 'D' Box .--/----- Type Filter Material -----Depth Filter Material ----- ,�.............................. ld � Distance to nearest: Well foundation _______________________ Property tine --- ............. - SEEPAGE PIT Depth __.,`i ------ Diameter __f/Number ---- /______________ Rock Filled Yes o No 0 i Water Table Depth --------- ------------------------Rock Size ------------------------..,------ �.. Distance to nearest: Well _,____Foundation ___....Q_____.__.. Prop. Line ______15_____________ REPAIR/ADDITION(Prev. Sanitation Permit# __________________________________________ Date __________________________________) Septic Tank (Specify Requirements) ___ _______________.--- ---___ Disposal Field (Specify Requirements) ------------ --•-•-------------•------------------------------------------------------------'------------------ ---------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- -------------- ------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) -.,.. I hereby certify that 1 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 Q--------------------------------------- Owner BY --- C,,. h --------- -s.�---- -------------- Title ---- — (If other than owner) �/ -- -------------------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED ----- ------------------------------------------------------------------------------------ --------------DATE ------ ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------- --------=-------------- ------------ ------------------- --------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------- ------------------------------------------------------- -------------------------------------------,-----------------------------------__----------------- Final Inspection by: --- -----------------------Date- --�-- - -1_--- SAN JOA UIN LOCAL HEALTHDISTRICT E. H. 9 1-'68 Rev. 5M