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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No, 7_y_'2— (Complete in Triplicate) ____-_. --------------------- ----------- ------- -------------- This Permit Expires i Year From Date Issued Date Issued 5' -�7 .�,{� - 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 compli nce with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION F ---------- ------------------------------------------------------------ TRACT - ------------------------------------------ Owner's Name - ---------- - -RQ01f�r----M01�? Z-------------- -----------------------------I---------Phone-------------- Address ------------------- oU_U.jT`� �1� ----------------------------------------- City -- RAY r Contractor's Name ______________ Q [u -------------------------------------------------------- ___________ I Installation will serve:-~ Residence artment House❑ Commercial ❑Trailer C Phone _____________________________ p curt i❑ 3 Motel ❑ Other----MO_b!-_(.__P-OMI ------------- Number of living units: �.� Number of bedrooms ___3___, _Garbage Grinder _---------- Lot Size ------Ac_Q I-E �'-----------------•--- Water Supply: Publia'System and name -------------------- - Private [tom Character of soil to a`depth of 3 feet: Sand [] Silt❑ Cla.y-❑., Peat❑ Sandy Loam ❑ Clay Loam t-•. k x. Hardpan ❑ Adobe°tg`fill'Material ------------ If yes, type ---------------------------- (Plot plan, showin � t''s - g aize of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepa e� it r� ,j r 1 p g- p permitted-if,.pvblic sewer.is available within 200 feet,) PACKAGE TREATMENT: [ ] SEPTIC TANK j [�- Size- ---------•1-�0�- --------- ------------ Liquid Depth -----�-z............... Capacity -3-40-------- T pe- { )iMaterial--C0-f0C11e�___ No. Compartments -------L----------- Distance Disante to nearest: Well _.�_-___-_Foundation _..___ ZS----- r° ---- Prop. Line .__S00------ � r "h" --- LEACHING LINE [ ] No: of Lines ------3--------------- Length of eac , Iine--------Q,0-------------- Total Length 'D' Box -2------ T k ype Filter Material �-_�iJ� Depth Filter Material _________-1�--_--•__---__ � Distance to nearest: Well ------3W-__------- Foundation ___- SEEPAGE PIT 30- & ----------- Property Line __ 0.."_?.............. �y [ 1 Depth -------------------- Diameter Number --------- Rock Filled Yes ❑ No ❑ Water Table Depth -------------- -_-----Rock Size ---------------__---- -----•----- � i Distance to nearest: Well _______________________________________Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sani#ation Permit# .-_____________________ I Date ------------- Septic Tank (Specify Requirements) ____-_- _____-__._--------------------------------------------------------------------- isposal Field (Specify Requirements) -,------------------------ --------------------------------------------------------------------------------------------------------------------------- -------------------------------- - --------------------------------------- ------------- --------------------------------- f ---------------------------------------------------------------- -------------------- ---------- -------- --- -- ---- I I ----------------------------------------------- ----------- (Drawexisting 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 mariner as to becom s biect to Workman's Compensation laws of California." Signed __ ---__-.- ---- U - ' ------ Owner BY (!f--- - - -- -- ---- ----------- - --- o#her than owner) ------ ---------------- ------------------------------------- Title - ------ -------- �------- FOR DEPARTMENT SE ONLY APPLICATION ACCEPTED BY __________ _ BUILDING PERMIT ISSUED DATE ��. ------------------- ---- DITIONAL COMMENTS -- ----------- ------- - ---- ----- - --------�--------- - - ------=--------------DATE -------------------=....................... -------------------------------------------- ------------------------------------------ ----------------- i --------------- ------------------------------------------------------- -------------------------- -------------------------------------------------------------------------- Final Inspection b ------------------------------------------------------ , __-- y ---D- 4� 7 • - -- ------- --- - ate - � --`- --------------- ------------------------ --- - SAN JOAQUIN LOCAL HEALTH RICT E. H. 9 1-'68 Rev. 5M