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FOR OFFICVCP-0 SE: APPLICATION FOR SANITATION PERMIT / ---`-�-�-`-�� ' -- - Permit No. �_'_fPIL/_6� ---- -- ----- (Complete in Triplicate) / _______ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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 ---?__!__575�-----;5,►---- i iff-6 ------------------CENSUS TRACT ______________..__.__.._.. Owner's Name (r''__Q_0_Z....... -f --------------- ------------------------ ---------------- -- -Phone ----------------------------•---- Address ---------- i� -----------------------------�-------�--------------------- -----------• City Contractor's Name -- __ _Q ___ / Q_P/_ _______________________________License #/'e e_g_�72 Phone 4�199ZZZ_Ad�,, Installation will serve: Residence 2?lCpartment House❑ Commercial ❑Trailer Court ;❑ Mote! M Other -------------------------------------------- Number ------------- ---------------- ---------- Number of living units:-- _____ Number of bedrooms ______Garbage Grinder -41� Lot Size - �_------40,A_............. Water Supply: Public System and name -----------------------------------------------------------------------.-- ----------------•-------------------Private J4 Character of soil to a depth of 3 feet: Sand'❑ Silt F] Clay ❑ Peat❑ Sandy Loam (r Clay Loam Hardpan ❑ Adobe E] 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,) PACKAGE TREATMENT [ ] SEPTIC TANK. ] Size______________________________________________ Liquid Depth ____________________-_- V Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- Distance to nearest: Well -------------------------- - -------Foundation ---------------------- Prop. Line ...................... v LEACHING LINE [ ] No. of Lines ------------------------ Length of each line____________________________ Total Length ----------------------------- 'D' __________________.._______'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- S Distance to nearest: Well ------------------------ Foundation Property Line -----------------.__--__ SEEPAGE PIT Depth ____ Diameter _______________ Number ---------------------------- Rock Filled Yes 0 No tw Water Table Depth --------------------------- ----------- --------Rock Size -------------------------------- Distance to nearest: Well --------------------------- ------------Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION{Prev. Sanitation Permit# -------------------------------------------- Date _____________________________-----1 Septic Tank (Specify Requirements) ------- / r Disposal Field (Specify Requirements) --- 7-r --------- P---------�,_ / yl---------------------------------- --------------------------- ------ ----------------------- I--------------------------------------------------------------------------------------------------------------------------------------------- (Draw - - (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 not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------ ------ ----------- Owner --- ----------------------------------- --------------------------- Title ----- '------------------------------------- other than owner) ev FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------- 1 - ----------------------------------------. DATE �G ---------------- -------- - ----- =-------- BUILDINGPERMIT ISSUED ------------------------------------------------------------------'------------------------L--------------DATE ------------------------------------------- ADDITIONALCOMMENTS -- ---- ---------------------------------------------------------------------------------------------------------------------------=----------------- --------- -------------------- ------------------------------------------------------------ ----------------------------------------------------------------------------------------- --- - -- ____________________ _____ _ ______ _ ____ ___________________________________ ____________ N _______________ & ---- Final Inspection ______ ____________________-_------------- _ _ _ ____ _ _ _______________________________ Date _________________________ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.