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FOR OFFICE USS: ----------- -------------------------------------------- APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ------------ --- -- ` Z 1 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-a ,plication is made in compliance with County Ordinance No. 549 and existing Rules•.ond-Regulations: :24 7.5 _ --�6C�- l---- try 1` ---- �_LPaN1 -------CENSUS TRACT _ JOB ADDRESS/LOCATION CATION =- __-- �/7 . � �. ,.------- --- - -----/0----•-r--�------ Owner's NameJ� � �--1 S' - r Phoned-��1 _ 1G-tT1_ Address ------ -� l7. --;�---- ��!/l1�/ ................ City 1�0 � ---------- --- ---------- Contractor's Name _-- _---- �.----- -- G-- ---Q- - - /� Q c -- f'----------------------License # 7 ----- Phone _c1 C�-__. __!�_ Installation will serve: Residence A artment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other-�------------------------------------------ Number of living units:----I------ Number of bedroom`s __3_.....Garbage Grinder __ -`�----- Lot Size .-- LRA --------- Water Supply: Public System and name ------------- ---------------------------------------------------------------------------------------.Private Character of soil to a depth of 3 feet: Sand'o' Silt❑ Clay ❑ Beat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe'❑ Fill Material __No-__ 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 [ ] SEPTIC TANK[ ] Size... 1Cf- -- -- ---------------------- Liquid Depth ---- ------ " Capacity -0,.__ Type R NF1_>___ Material___�3_A�C_____ No. Compartments .__ ......... Distance to nearest: Well ____s�6--_____________________Foundation ---,1.P---------- Prop. Line ------;5-- LEACHING LINE No. of Lines ____ . _____ - [ ] .G _______-__ Length of each line------- Total. Length ____- L........... 'D' Box yF_`a-_ Type Filter Material ---ROc_X.,..Depth Filter Material ------- _______________________ Distance to nearest: Well -----------S-0------ Foundation -------------/0 Property Line __- ............. SEEPAGE PIT [ ] Depth ___________________ Diameter '_'--------------- Number ---------------------------- Rock Filled Yes ❑ No Water Table Depth ------------------ -----------------------------Rock Size -------------------------------- Distance to nearest: Well _________• ____________________________Foundation ----- -------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ..........--------------------------------- Date __-____-__-___._-_-_----__________) Septic Tank (Specify Requirements) ------------------- -------------------------------- ---------------------------------------------I--------------------------- Disposal Field (Specify Requirements) _____________ __ -. .�. ------ ----- ---------- ------ -------- -- ------ --------------4=-- - f ------- =---------- -------------- ----------- -------- --- - - (Draw existing and requiked addition,on reverse side) I hereby certify that I have prepared this application and that the W. ork will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son 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 - - ACE--------------------- ----------------- -------- ----- --r -- -.- Owner C Y ---- Com' 2 { CFS------ -- Title ------------------------------------------------------ (If other than owner) ^ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED,'BY -------`�,:_ -0 ------ ---- ------------------ DATE ------ BUILDING PERMIT ISSUED__ -: __-_ -----------------------------------------------------DATE ------------------------ ADDITIONAL COMMENTS ______:___ __ ______ ________________ --- -------------------------------------- ------ -------- - -------------- --- -- ---------------- ----------- - ---------- ----- ---------------------------- - - -- ------ -------------------- Final Insp -------Date �� - ---------- ------------------------------------- - ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M