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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �`--------- -- ----- _ �"_.7.. a (Complete in Triplicate) Permit No. _ _ . __.___________-_-------_ This Permit Expires ] 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 application is made in compliance r4v th4ounty Ordinance No. 549 and existing Rules and Regulations: ]! !� W. IralPico /� JOB ADDRESS/LOCATION -------&_7ltiza LX, --- i 22i ,---f G- c ---------CENSUS TRACT -------`�-�----------- , Owner's Name c _I'(31r'12 _------ ' !<_1---------------------------------------------------------------------- -------Phone --------------------------------•-•- Address -- 3. _MA04C- _ )E----------- __ Cit 4 /4<am1w-----CA tl •---•----__----_ 0 /Contractor's Name ------------ -- 1 � ___`ry -----------------------------------------------------License # ------------------ ---- Phone ------------------------------ '7[nstallation will will serve: Residence KApartment House❑ Commercial :❑Trailer Court i❑ \�1 0 Motel ❑Other _-_ --____ o Number of living units:--- ------- Number of bedrooms ________Garbage Grinder -----�------ Lot Size ______ Water Supply: Public System and name ---------------------- ------- --- ---------------------•------------------------------------------------Private Q'r Character of soil to a depth of 3 feet: Sand'❑ 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 { ] SEPTIC TANK Ix Size______� - -- ----- -------- ------- Liquid Depth .__- ------------- Capacity jd�_ ______•__ Type PleaW---- Material____. No. Compartments ___-77Z�______- Distance to nearest: Wel! -------- _____________________Foundation ------ A? -------- Prop. Line ___ _ ------- LEACHING LINE [ ] No. of Lines Length of each line-------. 0-----_------ Tota! Length / d_____________ 'D'. Box VP_5_ ___�T.ype_Filter Material r9!______Depth Filter Material _____ 0L________________ Distance to nearest: Well ----63_�t---------- Foundation ___J)_-_r_. _g_ Prr p rty Line 77'67--------------- T SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes El No i❑ Water Table Depth ----------------------------------- ------------Rock Size -------------------------------- - Distance to nearest: Well ________________________________________Foundation --------------- ---- Prop. Line ................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ---- -------------- --------------------------------------------------------------=------------------------ _------------------------.._ 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 Sate 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: a "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 becom�esubject to Workman's Co��m//pensation laws of California." Signe! J T ------------------------- Owner NBY ----------------- --------------------- ---------------------------------------------------- Title -------- ----- ---- ------- - ----------------------------------------- (If other than owner) FOR DEPART , T U LY APPLICATION ACCEPTED BY -------------------------------- "' -. DATE µ -------------------- BUILDINGPERMIT ISSUED ----- --------------------------- ------------ -------------------------- ---- ------ - --------------DATE ------------------------------------------- ADDITIONALCOMMENTS ------------ --=--------------- -- --------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- --- - - ------------------------------------ --------------------- -- --------- - -- --- ------------------------------------------------------------------------------------- - - - Final Inspection by: ---------------------------------------- ------------------------- Date _fl -�� SAN JOAQUIN LOCAL HEALT DISTRICT E. H. 9 1-'68 Rev. 5M