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FOR OFFICEFUSf:' "' APPLICATION FOR SANITATION PERMIT ------------------------------------ (Complete in Triplicate) Permit No. _171c,_._-_Z:_!17 (A This Permit Expires 1 Year From Date Issued Date Issued 47_Z ') _________________________________________________________ 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 .______________________________________________________ CENSUS TRACT --------------.___________ Owner's Name �1a---pt1-I/ --------------�Zv-�� ------------------------y--�---= �----------------Phone Address ✓? �; - � j�6n --- 1 City(:_!_ tV1E� 1 p Contractor's Name ---1-0-- A r4_ i�jP________-____________/______________License #�-��f�--- Phone _A_ _� 5---- Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other --------g------------------------------------ Number of living units:__________ Number of bedrooms .�J__------Garbage Grinder __________ Lot Size 7X3 .0 _2-- -- ---- -- - -................... 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 ___________________________ (Pl'ot 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 f ] Size__'S�_y_ l?___ ________ Liquid Depth _' .............. Capacity/;_?OQ------- Type No. Compartments 2__________________ .................. N, Distance ' ' Distance to nearest: Well __d__Q____--------------------- Foundation _-_________________,Prop. Line ------- LEACHING LINE [ ] No. of Lines __3--------------- Length of each line--- ------------ ---- Total Length ----- vp............ 'D' Box __l_____ Type Filter Material CA--.Depth Filter Material ___/Q_________________________________ Distance to nearest: Well ------ 7" .1------ Foundation --- ______ ......_ Property Line �?_______.______...___ SEEPAGE PIT [ ] Depth _-_-______-______ Diameter _______________ Number ______--________-________ Rock Filled Yes ❑ No 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 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: "1 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 ---- -- - --- ---- r-- --------------------------- Owner ----- --- - - BY �- ' Title - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- !----------------------------- ----------------------- DATE --------51.774�57'_7c ----------- BUILDING PERMIT ISSUED --------------------------------------_ -- ---DATE ---------------------------------------- ------------------------------------------------------------ ADDITIONALCOMMENTS ------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- - - - - - - - - - - - ----------------------------------------- ----------- - ---- - ---------- -- - - -- - ----- ---- -- ------- ------------=------- Final Inspection by: DoT`' Date `l-d�--_��- ----------------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M