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E FOR OFFICE USE: ,. ,� ,� ; APPLICATION FOR SANITATION PERMIT --------------- _„ ---------------------- Permit No. _7_Z_- 3 -7 (Complete in Triplicate) ---------_. __________________________ This Permit Expires I Year From Date Issued 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 plic o1n s,r�gJ n�cQ`pli�n�epi with Co�u�n3 Ordinance N 9 pnd existing Rules and Regulations: ! vo F.As 4 tf�ee 11 44 Rd waGdri+A JOB ADDRESS/LOCATIONa_flaw_-j-__,--Tn"- -- _,_44--------------------------------CENSUS TRACT -------------------------- Owner's Name --------------k�----DR!I-il---------------------------------------------------------- --------------------------------Phone __' 3 v��--------- Address ---------------------------Zr----t - �YY•ar�r- 'fI City -------- -------------•----------------- ------------- - - - --- Contractor's Name _.------------- --------------------------- ------ License # -------- -------------- Phone ------------------------------ Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- Number of living units;------i----- Number of bedrooms _______Garbage Grinder ------------ Lot Size --- ------- Water Supply: Public System and name -------------------------------------------------------------- ------------------------------------------------Private, Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam K Hardpan ❑ Adobe-❑ 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 see age,pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK .Size_____________-____________ti_ )' ---`-_ Liquid Depth __,____________________ 6% Capacity �F______ Material&44G __ No. Compartments P Y f Type ---11--------------- I'll-- (a Distance to nearest: Well -------- A�7! �-.J'ef' � Foundation ......��'��r Prop. Line M_ -t---- LEACHING LINE TA No, of Line ` ------------- Le;grtb of each ,lirie____k Total Length ___- ef D' Box ___ Type Filter Mater ialw_rw--Koh-_Depth Filter Material -----10 ,:i �? Distance to nearest: Wel! __70�+ _______--Foundation _� ° ___ Property Line - F C SEEPAGE PIT [ ]' Depth -------------------- ________ Rock Filled Yes E] No 7❑ --____--f biometer ----`---. _ --- Number ----------------- Water Table,Depth ---------------------Rock Size --------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------_____--___----_} SepticTank (Specify Requir"ements) ---------------------------------------------------------------------------------- --------------------------------------------------------- DisposalField (Specify Requirements) -------------------------------•-------------------------------------------------------------------------------------•--------------- ----------------------- - ----------------------------------------------- --------------------------------------------------------------------- ------ - -------------- ' (Draw existing 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 erformance'of the work for which this permit is issued, I shall not employ any person in such manner as to become u to orkman's Compensation laws of California." Signed ---- . .................................................... --------- -- - ----- ------ Owner By ----------------------------------------- ---------- ------ Title --------------- ------ (If other than owner) fj�R DEPARTMENT USE ONLY OF APPLICATION ACCEPTED BY - - - --- ------------ ----------------------------------------------- DATE -�7--- -- 72 BUILDING PERMIT ISSUED ------------- ------------------------------- ---------------------------------------------- -DATE ADDITIONALCOMMENTS =-------------------- r-_------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------- ---------------- ------------------------------- ------------------------- -------------------------------- ----------------------------------------------------------------------------------------------------------- ----- --------- --------- ---- - - -- - -- Final Ins ection b --_.___-_. Date ___ -_'�� ___ P y- -------------------------------------------- - ---------------------------- SAN JOAQUIN LOCA HEAL DISTRICT E. H. 9 1-'68 Rev. 5M