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FOR OFFICE USE: APPUCATION FOR SANITATION PERMIT Permit No. __._ _r__ __ � qe 2'�Q �. - (Complete in Triplicate) _ -__- A�/7 . _. _----____----_-- This Permit Expires 1 Year From Date Issued Date Issued 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 . '17 5 ?' L L l --------------------------------CENSUS TRACT -------------------------- Owner's Name ----D/N/V-$----- ------------------- ------------------------------------- ------ Phone ------------------------------------ Address ------ _.___Lf ---------------------------------------------- __ Cit -- -- Contractor's Name -----------------------------------License # ---- Phone�tl-y�---- Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number of living units:---I------- Number of bedrooms _aZ-------Garbage Grinder _NQ Lot Size _a2. --f CE ------------- 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 W 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,) i PACKAGE TREATMENT { ] SEPTIC TANK:M Size---1,2v-Q---6;92--------------------- Liquid Depth __----_-____-- ........ Capacity 117-0016;k Type Material Compartments _2................ \� Distance to nearest: Well �___---_ Prop. Line __ _�............ v ------------------------------------Foundation ----1-�--- LEACHING LINE ;� No. of Lines --------l----------- __ Length of each line-------- ------ Total Length ,____ ............. 'D' Box ------------ Type Filter Material ____________________Depth Filter Material --------------------........................ Distance to nearest: Well --------------------- Foundation ----0a_`---------- Property Line _5_.................. SEEPAGE PIT [ocJ Depth _v2s__�_.--__- Diameter __ _``_____ Number ---------I-------------- Rock Filled Yes '® No Water Table Depth --------t 0-0--------------------/_..__..__.Rock Size __I_. '/ ----.--------.--- Distance to nearest: Well ____�------------------------------Foundation ---1_©__- _._. Prop. Line ..:IC.............. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------_-------------------------) , Septic Tank (Specify Requirements) -------------------------------------------------------- --------------------------------------------------------- Disposal Field (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 Joaqui �'4 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 su ctto o �maann'' Compensation laws of California." Signed ..------G "" Owner BY -------------- ----------------- ---------------------------------------------------------------------- Title ----------------------------------------------------------- ------------ (If other than owner) FORD ARTMENT USE ONLY APPLICATION ACCEPTED BY ____ ._-____ DATE 1-2 �'---- ------------ BUILDINGPERMIT ISSUED -------------------- ---------------- ----------------------- --------------DATE ------------------ 7— ADDITIONALCOMMENTS ----------------------------- -----------------------------------------=--------------------------- ------------------------------------------------------------------------------------------ --------------------------------------------------------- ------------------------------------------------ --------------------------------------------------------------------------------------- --------------- ---------------------------------------,-- ----------------------------- ---------------- -------------------------------------------------------- __� ---/--e---- ---- ------ - Date ___j ------ ---Final Inspection by: _ SAN JOAQUIN LOCAL HEALTH DISTRICT �— E. H. 9 1-'68 Rev. 5M