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!+ FOF OFFICE USE: APPLICATION FOR SANITATION PERMIT ,Permit No. _ it (Zomplete in Triplicate) ...... ----------•------------------ ----------- ---------- ' 1�--------------------------------------------------------- This Permit Expires i Year From Date Issued Date Issued �=�___�/ 4 11 Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein ? described. This application-is,.made in compliance with County Ordinance No. 549 and existing Rules and Regulations: a JOB ADDRESS/LO YATON j1�/.$'- ✓x 1J 2; j-- ' f1.�tre-/ 0'�' l,( ENSUS TRACT _2------------ -------- Owner's - ._- # Owner's Name h/Lf----- AO 0 r V&f--------------------------------------------------------------------------Phone ------ Address c3 r� ( r t= =---------------------------------------•--. Cit �� ------------------------------------------ il v 4'�1 J -- �! Contractor's Nameea -------------- # ---------:--------_--_-- Phone _Yl_J-_._ Installation will serve: Residence [] Apartment House'(] Commercial railer Court ❑ Motel ❑Other -------------------------------------------- -Number ------------------------------- ---- --- Number of living units:___'------ Number of bedrooms --— Grinder ------------ Lot Size . �e_e --------------- Water-Supply: ______________ Water Supply: Public System and name ----------- ��---------------------------------------------------------------Private c Character of soil to a depth of 3 feet: Sand' Silt❑ Gay ❑, Peat❑ Sandy Loam ❑ Clay Loom :❑ Hardpan ❑ Adobe-❑ Fill Material ------------ If yes,type ----------------"--__-______ -� `a (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 seep geit permitted if public sewer is available within 200 feet,] Ory �1 :'�±PACKAGE TREATMENT [ ] SEPTIC TANK�[ °�� Size________________________________________________ Liquid Depth __________._____________ l� .1 Capacity -------------------- Type -------------------- Material-------- ------------- No. Compartments ------ ---------- ; !, J istance to nearest: Well ------------------------------------Foundation ---------------------_ Prop. Line -------____-----__.--- �] LEACHING LINE `l [ o. of Lines ----------------- Length of each line----- 110 _ Total Length c �----------------- Ij Q' Box Na_____ Type Filter Mate riakl: _ _Depth Filter Material ------ `�__________ _�_______._ + Distance to nearest: Well ----------- Foundation _IA�Plq-----_------- Property Line. ___4__________________� '# SEEPAGE PIT ( ]z Depth ____ Diameter _______________ Number ---------------------------- Rock Filled Yes F] No s❑ Water Table Depth -------------------------Rock Size -------------------------------- aDistance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- E] REPAIR/ADDITION(Prev. Sanitation Permit# ___AJ-�-7-------------------- '---_ Date ________)I '1 Septic Tank (Specify Requirements) ------------ --------------------------------------------- ---------------------------------- ---------------------------- li Disposal Field (Specify Requirements) ______________________________________ _ 1i fi, + ---------------- --=---, = ----- ------------------------ --------------------------------------= ------------------------------- --- _ ° (Draw existing and required addition on reverse side] I hereby certify f•that-Ixhave prepared-jhis,application_and_thai"the`. vn64k 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 liven- ' u sed agents signature certifies the following: 1 i' "I certify that in they'erformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subiect to Workman's Compensation laws of California." Signed --------; Owner sBy ----- Title ----------- ------------------------------------------------------------ A (If er t an own r} FOR .DE ARTMENT USE ONLY APPLICATION ACCEPTED BY -`_:-_ r___ __�__ r�P.-� _ BUILDING PERMIT ISSUED ---------------------------------- --------------------- -------DATE ------------- --------------- ---------- ADDITIONAL COMM _ ec _ s - 5trr�-' -----�1`-gyp- -- ------- ------------------------------------------------------- �,,. �, _ ------------ ------------- --------------------- y 3� la Final Inspection by. -A..... = -------- --- - -•--- -- ---------- ----- Date - - ---------------_----- 1 ,1 SAN JOAQUIN' LOCAL HEALTH DISTRICT r I f E.-N. 9 1-'68 Rev. 5M