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_ FOR OFFICE USE: APPLICATION FOR,SANITATION PERMIT -------------------------------- -- 0 Permit No. --___9 --_--~-957 (Cogiplete in Triplicate) p' /Xlr/ _____ is 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 mad in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOCATION / --- ----CENSUS TRACT ----------` --------------- Owner's Name j 4 GO G ' t / JK -----��-�G':�----------------- - ------ --- -------------=-------- - ----------Phone ------ ------------�--------------- - Addre�---/Ia I City --------------------- -- , ' _ Contractor's Name ---- ,�1 =1 _----+ -P1y'� -( -c�-- ---------------License '-G--g- _ Phone --- _ _�;3 _ .�,? • � - i Installation will serve: Residence [1Aparfinent HouseE] Commercial ❑Trailer Court ❑ Motel ❑ Other --------------- ----------------------------- Number of living units:---I___-- Number of bedrooms ___'-"_.,__Garbage Grinder ----------._ Lot Size �_ �3 '' --{..� � ----------------- Water Supply. Public System and name,_,._(141bT�__Ar�_Q_-----A"c R ez---------------------------------------------- Private ❑ Character of soil to a depth of 3 feet: Sand'❑ -Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam EK I Hardpan ❑ Adobe ❑ . Fill Material ------------ If yes, type ---------------------f------ 1 (Plot plan, showing 'size of-I t location of system in relation to wells, buildings, etc. `must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit perrniffed fpublic sewer is available within 200 feet,J PACKAGE TREATMENT ( SEPTIC TANK [ ] 'Size---------------------t_-___--___-------- Liquid Depth --_---r-� "----___-- Distance to 'nearest: Vdefple� t• ( I Material__ cXfc Nob;Compartments`------off,._/_.___ r t P play-------,�`-.o_ .....---Foundation -----I- -----------.Prop. Line'_- LEACHING LINE rV No. of Lines -------)„------------- Length of each line------- 1--- .�il - - - ..-�_-- Total Length �_ / r,-� -. �" D' Box ------____-- Type Filter Material --R_Q-C19,------Depth Filter Material -------,{7 �J--------- ---.. -- Distance to nearest: Well -----__.------:_____.___ Foundation ---- Property Line, ---------___-_____-_-_f SEEPAGE PIT ' Depth --- , `.-------- Diameter -14-------- Nurnber-- ..— Z.--------------- -Rock-Filled,.y..-•Yes [� No 0Water Table Depth -----------�,b---------------------------- -Rock-Size ---- =Distance to nearest: Well -----/`�,,- - ` s `E Y .-• Foundation-=?"14.� "; Prop: Line ------`• ---------- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ______________� _--- Septic Tank (Specify Requirements) f ---- ------------`------------------ ----------------------------------------------------------- Disposal Field {Specify Requirements) -----________ _ 1 _ �f ------------------------------------------------------- --------- ------------------------------------------------------------ ---'�- - ------------------- ------------------------------------------ -- l (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,I shall notemploy any person in such manner as to become subject to Workman's Compensation lawslof.California." Signed1 _ - � '_PJ-�. , ----------- ---- Owner 1 t BY -- ---------------------- Title ------- (!f other than owner) 1\ + C- 1 O PARTMENT USE'ONLY APPLICATION ACCEPTED BY ------- - - --------------- -------- -------------- DATE _.�/y_/ .-�. _ _ - ---- -- ------ G PERMIT ISSUED ---- ---- --- - ------------- DATE ------------ ------- ADDITIONAL COMMENTS ------- - --- '-- -- -- ----- - --- -- ---- - -- ------ i FinalInspection by: ------------------------- --------- --------------- - --------- --------------; Date -------------------------- --'-------------- SAN JOAQUIN LOCAL HEALTH 61STRICT E. H. 9 1-'68 Rev. 5M. i