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r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT. (Complete in Triplicate) Permit No: ___________........ _ ---------=---------------------- - - \�----- ?� Date Issued7L -----------------------___-____-_________-_-------- This Permit Expires 1 Year From Date Issue 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 . - p v�/�� 3 A-!' 0 ' /-___ -------------------CENSUS TRACT ---�-- �/--- Owner's Name --y&-_/------- --------------------------------------------- I-------------------Phone ------------------------------- Address --------�,?, --- W� lj - -------AL��-- -------------- City - �14?r� 1' ?r��A--------------------------------------- Contractor's Name ------- —-------------------------------------License # 9?,9 Sk_.Phone _ 23_9_V�•�� Installation will serve: Residence �partment House❑ Commercial ❑Trailer Court F1 Motel ❑Other ----------------------------------------- Number of living units:__------ Number of bedrooms . ------ Grinder -__-__---- Lot Size _-- ---- _______ Water Supply: Public System and name ------------------------------- ----------------------------------------------------------- -------------------Private ❑ Character of soil to a depth of 3 feet: Sand'WI-lilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type -------------_____--_____ a (Pl'ot plan, showing size of lot, location of system in lation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepa pit permitted if public sewer isavailablewithin 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ S -__'_ ize_____-�- _ ___-"__`J_-_----------------- Liquid Depth ----- -_----_________ Cacity ------ Type FXp5 'AS_Material---------------------- No. Compartments ........... istance to nearest: Well ----5,;!2-----------------------Foundation __ -______---___Prop. Line ------------ LEACHING LINE [ No. of Lines ---_---�----__------ Length of each line----dr1--a------------- Total Length ,___P_�1_-g� ............ t� /> 'D' Box __--d------ Type Filter Material � .a _Depth Filter Material ______1��_____________________________ i Distance to nearest: Well ----- _0-___-__---_ Foundation ----- ------------------ Property Line ________________________ SEEPAGE PIT [ ] Depth -------------------- Diameter -_-__--__-__--- Number ---------------------------- Rock Filled Yes '❑ No i❑ 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) eZ/ --` ---- ---- ��------------V-'------------------------------------------•----------- ------------------------------------------------------- -----------------------------It,R�C-a4T7WC---=---------- --- ------------------------ --------------------------------- -------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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, 1 shall not employ any person in such manner as to become subject to W kman' Comp sation laws of California." Signed - - - ---------------------------- Owner By - ------------------------------------------------- --------- ------------------------ Title ----------- ------------ ------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -- -= -=--------------------------------------------- ----------------- ------ DATE - 77: -�L"-- BUILDING PERMIT ISSUED ------------------------------•--------------------------------------------------------------------------DATE -------------------- -------------- ....... ADDITIONALCOMMENTS -- ---- ---------------------------- ---------------------- -------------------------------------------------•----------__--------------- ------- -- -------------------- ------ - ----------_---- -- ---- -------------------------- -------------------------------------------------------- -------------- ----- - --- - --- - --- -- -------- - ---- --------- -- --- -- --- Final Inspection Date ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ..