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FOR OFFICE USE: " ,� APPLICATION FOR SANITATION PERMIT r (Complete in Triplicate) Permit ------------------------------------------------ -------- ------- 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 ---- .r.'-~ --, �f.4 �.X _77-Z-5- ------------------------CENSUS TRACT -------------- ........... Owner's Name ----------------------------------------------------------------------------Phone. --�s�.i�. Address ----- - 257�., t� �/�#1 ---------------- --- ----------------- city --------------------- ..........-- Contractor's Name ----------.License # ------------------------ Phone _174;;j9-:. 1-4-02--- Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court ❑ Motel Other -------------------------------------------- ` Number of living units:_________ Number of bedrooms _��r_,.Garbage Grinder ------------ Lot Size "__ `x ` o Water Supply: Public System and name _____� 57n ________________________________________Private ❑ Character of soil to a depth of 3 feet: Sand Silt Clay Peat 19and Loam Clay Loam p '❑ ❑ Y ❑ ❑ Y ❑ Y ❑ Hardpan ❑ Adobe Fill Material __________ If yes, type ---------------------------- (Plot plan, showing size of lot, location of,,.system i_ri relatlon,to wells:buil@ngs,- etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is civailable within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] .f: ,: , Size----------------------------- ----_.------:----- Liquid Depth ---------------------.---_- • Capacity Type �hllaterial. .; 4------ `.. No. Compartments Distance to nearest: Well ",}___""_ ':'__.Founda#ion ____ _______________ Prop. Line ._..._._______________ LEACHING LINE [ ] No. of Lihes _______________ length of each line---------------------.------ Total Length --.-__.____.______________-- 'D' Box ------------ Type Filter Material ___________________Depth Filter Material __--..--____________-____________-__-.--_-__ Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------....__._____ SEEPAGE PIT [ ] Depth __,oZ.S--------- Diameter ;_, _��__ Number ----------/__+__�____ Rock Filled Yes ' No Water Table Depth --------l2�-------------------------------Rock Size ------ -I----�--�-------- Distance to nearest: Well ___ . ._-----------------Foundation _40------ Prop. Line --- ------------ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------_) Septic Tank (Specify Requirements) --------------------------------------------------------------------------------- ----------:----------------------------------------------- Disposai Field (Specify Requirements) _________________ ______________________________ __ --,.? �- - 1—'-------------------------- ------------------------ �rciwexisting d requir d 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 Son 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 cubject to Workrs' Compensation laws of California." Signed -------- ------- Owner ---.`. BY --- ---�-�----�--- ---- -- -- - Title .��,�.-,�eC_� ----�---------------- ---- -- f other than owner] ' r F ARTMENT USE ONLY APPLICATION ACCEPTED BY DATE -- F= "T ---------------- BUILDING PERMIT ISSUED -- _ J---- - --------- -------------- DATE --__--- ------ ---- --__ ------------ A ITIONAL COM T54' -fie i �7 yam, ------- -'-�- ------ - -- -- -------------------------------------- -- -- --- - - ------- -- -------------------------------------------------------------------------------------------`------------------------------------- Final Inspection b __Date __ SAOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 ev.5M a�