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FOR OFFICE USE: � �AlOPLICATION FOR SANITATION PERMIT - ----- l - '�"-'"--- ---------------------------------- (Complete in Triplicate) Permit No. .7.�-.6.�... . _________________________ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made tot 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: 114,3 13 / J B ADDRESS/LOCATION .-----l! �!r�'0" �1/-/---------------- �` ."--------CENSUS TRACT Owner's Name --------- C' Vic. Gra" -� 9Ks-------------------------------------------------------- -------------------Phone _� 9 1. _`�.`.--------- Address 3!'S- 1t'l?tri r /- ---w rca----------------------- City lj.?_04a------------------------------------------------- !} Contractor's Name -----------se _- -- ,��C��^�G1 -License # ---- - ------ Phone --------------------------- Installation will serve: Residence ❑Apartment House❑ Commercial railer Court Motel ❑Other ------------------------------- ------------ Number of living units:------------ 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 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 seepa pit permitted if public sewer is available within 200 feet,) `, PACKAGE TREATMENT { ] SEPTIC TANK f Size----------------------------------- Liquid Depth _._-.-`��_._-- --_ Capacity _/ ® ..,__ Type�1 ------ Materiale�-_- No. Compartments _Z.._............ stance to nearest: Well `_______________________Foundation AC'-------------- Prop. Line -----47........... LEACHING LINE- [& No. of Lines --------___ j--------------- Length of each line-__.X0----- _----- Total Length _-- Q.............. 1 'D' Box ------------ Type ,Filter Material�i�'l_-i�_..►b�*Depth Filter.Material -------------- ............. Distance to nearest: Well 44:992_____________ Foundation _.Ate-------------- Property Line ............ SEEPAGE PIT [ j Depth ------------- Diameter -_............. Number -----------.----------------- Rock Filled Yes '❑ No 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ------------------• -------. --------------------------- Disposal Field (Specify Requirements) ------------- ---------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 th ark for which this permit is issued, 1 shall not employ any person in such manner as to becomee b' c orkman's en ation laws of California." Signed { Owner BY ------------------------------------------------------------------------------------------------------ Title ------------------------------------------------------------------------ (If other than owner) kOp DE ARTMENT USE ONLY APPLICATION ACCEPTED BY --------- `---'-'-------------------------------------------------- DATE ------- _114V7 Z BUILDING PERMIT ISSUED ----_-.._._---.-------_ -.-...___DATE -----------......-----------_----------_- ADDITIONAL . . ------------- -------------------------------------------------- - -- - -------------------- ADDITIONALCOMMENTS ------------- ------------------- ------------------------------------------------------------------- -----=--------------- ----------- ------------- ------------------------------------ -------------------------------------------------------------------------------------------------------------------------------- --------------------- ----------------------------------------- --- -- ------------------------------------- --------------------------------------------------------------------------- ------------ ---------------------------------- - - --------------------------------------- ----------- - --- --------------------- ------------- ----------- -- --------- ----- ---- Final Inspection by: -�� ----------------- ----- ----------------- -------------- ------------------ Date ^'?- --- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M