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COR OFFICE USE: To- APPLICATION FOR SANITATION PERMIT ------- - ;_ i (Complete in Triplicate) Permit No. .7-�= 3-L ---------------- This Permit Expires 1 Year From Date Issued Date Issued __�1~_."0-_31 �r 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 m//adee' in compliance with County Ordinance No. 549 arid existing Rules and Regulations: JOB ADDRESS/LOCATION_(�_�-�--k_+_�.OC-----,l/olw�,-# ,� !- -- -L.►-- -.--CENSUS TR CT __�-` ------ .y(f ® C7 -- Owner's Nam �j �f��/ �---- �/, /• -------------------------------------Phone, !•- a �r Address ---VIAle_4� f�T -------------------------------------------------------- City ----------------------------------------------- ---- -------- -----------------------•--------- Contractor's Name .- _ �^' Xi License44---- Phone-_r�� .� Installation will serve: Residence ❑Apartment House-E] Commercial ❑Trailer Court ;❑ Motel 14_ether&W-k50Z_ y Number of living units,.-4)----- Number of bedrooms -----0---•Garbage Grinder _-P------ Lot Size _SCO c_XX Water Supply: Public System and name ------------------------------------ R Private Character of soil to a depth of 3 feet: Sand'WPXSilt❑ 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,) �[� ry PACKAGE TREATMENT [ I SEPTIC TANK'[ Size _x7--, .X Liquid Depth .7�-___ t Capacity/;,�_---- Typ �:iW Materia TF No. Compartments Distance to nearest: Well __,��--�_________________Foundation _fl�-------------- ,�` Prop. Line ------------------•--- LEACHING LINE r No. of Lines Length r �j �. [ - ----------- ---- - Len th of each line-___-- ------------------_-- Total Length _!-C�_-•------•--••---- t rr V 'D' BoxAV�_____ Type Filter Materiaf ch--______Depth Filter Material _/_5? Distance to nearest: Well 1.0-40___ ________ Foundation 1Q___---------.__ Property Line 6_ pY * -- ---------------- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C] Water Table Depth ----------------------- - ----Rock Size ADDITIONstance to nearest: Well -------._______________.________-'..---Foundation -------------------- Prop. Line --------------- ...... REPAIR Prev. / ( Sanitation Permit# ------- ------------------------------------ Date ---------•---------------- ) Xf Septic Tank (Specify Requirements) ----------------------------------------------------- Disposal ---------------- -----------------------Disposal Field (Specify Requirements) ------------------------------ ------------I- ____________------------------------------------- ------------------------------------------------------------------------------------------------------------------- ---------------------------------------- r (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, Stcte 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 --- ----------' Owner ----------------- --- ---- ---- ----- - ----- ------ ----- BY --------- !. . .... Title _o {/ - -- -- - - ----------- (If other than owner) , FOR DEPARTMEN USE ONLY APPLICATION ACCEPTED BY _-_---a { - _c_ DATE �l BUILDING PERMIT ISSUED ----_____________ --------------------------- -_DATE _..--- F ---------- ------------------ -COMMENTS _-___ ----------------------------------- ----- ___________________----------______ ---- ---_.______F__.___._-- _______ _________ ____________________ 4--- _____._____._____-_______-________ ___________________ --__________---_- _____-_-.______ -__ _-____-__________-________________________________.Final Inspec ' - - ---- --r-------------- -------Date ---- ------------- k -/-/- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M _