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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------- -----f----------------------- Permit No. (Complete in Triplicate) ------------- --- --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued l ..0, Application is hereby made to the San Joaquin Local Health District for a permit to�-cdnstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: F / f JOB ADDRESS/LOCATION .---- -�------��f----------------------------------------------- ---------------- ---- -----CENSUS TRACT ---------- ............... Owner's Name /� G � - _ i $ ',-.e ' ------- --- -- -------------- _ ---------------------- --------- - Phone -------------------------------=---- Address -----------------�- .` j 1 1//.tf r G o /?W Cit n ,7Y�c ---- -------- Y --------- ------ ` ? ' ' Contractor's Name --- 0 n: vSG sS- 7� ----- --/-�---------------------License # � ---- ----- Installation will serve: Residence 2g Apartment House❑ Commercial ❑Trailer Court 0 Motel ❑Other -------------------------------------------- f)c Number of living units:_.____.__.. Number of bedrooms __' __-_.Garbage Grinder t `'.._ Lot Size ______....._..................-__._:._.... T Water Supply: Public System and name ---------------------- ----------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .F] Clay.Loam,E] Hardpan ❑ Adobe ❑ Fill Material _ If yes, type (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septici tank or seepage'p'it~permitted if public sewer is available within 200 feet,) V PACKAGE TREATMENT [ I SEPTIC TANK [ ] Size---------------------------------- - ------------ Liquid Depth ------------.--.- -_.-__ \[1 Capacity ------------ TYpe.:---------'----------- Material-----------------k---- No. Compartments ................ -�---- Distance fo nearest: .Well--------------------------------------Foundation ---------------------- Prop, Line --------------------- -des LEACHING LINE { ] No. of Lines ------- -------- -------,Length of each line---------------------.------ Total Length ,-____-.__.,.__..._...---- � 'D' Box -- ---. ---- Type Filter Material ------------'----_--Depth Filter Material -------------------------------------- t - Distance to nearest: Well __._..__-.-_. ....--_. Foundation .................. Property Line ___._...-..._._.-.....__ SEEPAGE PIT [ ] Depth ____ ---------------- Diameter ... ............ .Number --------------.-.------------ Rock Filled Yes ❑ No i❑ t Water Table Depth ------------------------------------------------Rock Size - ------------- Distance to nearest: Well .-__.._--__-._____-______-____._._-Foundation -------------------- Prop._ Line ______________________ I REPAIR/ADDITION(Prev. Sanitation Permit# --------.----------------------------------- Date ..__------------._._..___.__._._) Septic Tank (Specify Requirements) --=------- ---- ------.-------------------------- ------------------------ --------------------------- Disposal Field (Specify Re.quirements) -?-Cl-o------- - ---------------- --------- -------------- - --------------------------------------------------------- I , 16�, -Yry 5eev"MY, 1 7 -------------------------------------------------------- --------- ---- -- ----- - ------- --- ----------- -------------- ---------------------------------------- -------------------------------------------------------------------- -------------------------------------------- --------------------------------------------------------------- ----.-. -__ ,------------------_.-----------:--------------------------------.-------_------------------------------------------------------- ---------------- -------------------- _ .. __ - - . = _. f � _� 'Prow existing and required dddition on reverse sidej'�� ` `"--" u 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-. r `-- /� --� -�-------Flu------------------ ----------- Owner _ _ y 5 O r w r n Title !? /Y eq J�.> BY ` . ' (if other than owner): FOR DEPARTMENT U EJq LY I ' APPLICATION ACCEPTED BY ------ _ DATE -- Y7-7 ----------- ------ BUILDING PERMIT ISSUED ------------- - = -----DATE ------------------------------------------- ADDITIONAL COMMENTS -------------i-------------------------------------- ------------------------= = i ---------- ------------- ----------------- ------------------------------------------------------------------------------------------------ -- -------------- - -------------------- - --=------- FinalInspection by: ------- -------------------------•------------------------------------------- ------ _-- --------------Date ..1A--------------------- -------------- SAN -----Y------ -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H, 9 1-'68 Rev. 5M.