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FOR OFFICE USE: - �1 b -14 J_C,v-2'3Gs APPLICATION FOR SANITATION PERMIT ----- ---------------- ---------- � - Permit No. --------------------------------------------------- --- -/-1�J-7 (,� � -- - (Complete in Triplicate){ �� _________________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued __________________4 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 with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION �C----------------- ----------------_--------------------------------- CENSUS TRACT --------------_---_---- Owner's Name t`j=Sr� l -/ =1,Y- � n�--- --------------------------------- ------1-----------Phone � 1 Address ----- `7._c!5;--�----- ,----g-1 r-_X� --I _X-- --. City _121&2_&,/1= (;'1--1 ............................................ Contractor's Name =' 0l �il�'/ -------------------------------- License #� %�. Phoner �'—f s Installation will serve: Residence)KApartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ------------------------------------------- Number of living units:------It_- Number of bedrooms _.z3----Garbage Grinder ------------ Lot Size -_________________ Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private [� Character of soil to a depth of 3 feet: Sand P3Silt❑ 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 [ I SEPTIC TANK,[ ] Size____________________ __________-____r_ _ _ Liquid Depth -----------.4_________-__- s Capacity -------------------- Type -------------------- Mater' -- ---------------- Compartments --- .................. �A Distance to nearest: Well ______________________________ __F ndation --------------------- Prop. Line ---------_-rl_....__ N LEACHING LINE [ ] No. of Lines ------------------------ Length of each ine--------------- ------------ Total Length ,_____-____.___-_-_-___._... %A 'D' Box ------------ Type Filter Material ______ ___________Depth ilter Material ----------_------------------_.............. Distance to nearest: Well ______________________ _ Foundation ____________________ Property Line --------------_------- SEEPAGE ___-_-_.___., ------_SEEPAGE PIT [ ] Depth ___________________ Diameter _______ ...... Number . ----------- -------------- Rock Filled Yes '❑ No i❑ �• Water Table Depth ------------------------ ----------------------- ck Size -------------------------------- �6 b Distance to nearest: Well ________ _ _________________--__ -Foundation -------------------- Prop. Line ...................... � REPAIR/ADDITION(Prev. Sanitation Permit# ______________ _ __ ___________________ _ ate ----------------------------------) e Septic Tank (Specify Requirements) ------------------------ ---------------------------------------------------------------------------------__---------------------------- G Disposal Field (Specify Requirements) --------------------------------------------------------------------- ------ --- ----- --------- ----- --------------- f �/ � _--- '-f. 'd ----- -- � F� ---/�--- ------'-/------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 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 I ------ Owner ---------- a By --- - - ` -�,�----- ---- FOR ------ ------------------------ Title ------------------------------------------------------------------------ (if other than own r� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _______ DATE _____- -- --- ------------------------------------------------------------------ -- BUILDING t PERMIT ISSUED ---------------------- ------------------------------------------------------------------ --------------DATE -------------------------------------- ADDITIONALCOMMENTS --------- -------------------------------------------------- ---------------------------------------------------------------------------- I-------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- ------------------------------------------------------------------------------------- --------------------------------- ----------------------------------------------------,- ----------------------------- --------------------------------------- -,-`==-------------------------------------------------------------------------------------- FinalInspection by: ------------------- -----------------" ---------------------------.-----------------------------------------.Date ------ ---------------------- -�----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M `v