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/ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 411K�Z-----------�/`— ------ (Complete in Triplicate) Permit No. -- �-s�3 • --------------------------------------------------- Date Issued _--/_�..71 --------------------------------------------------------- This Permit Expires 1 Year From Date Issued ? =- Ec7 co t/+E 1 73-- 2co—Q_S pp11,7ion is 19;e 5,-_7701,) made tote San Joaquin Local Health District for a permit to construct and install the work herein described. This applicatim in compliance with County Ordinance No. 549 and existing Rules and Regulations: (22 .f � JOB ADDRESS/LOCA ONO -- _C_-- __ -- - 16k ----------CENSUS TRACT --------------------------- Owner's Name ----- , �� --1 e------ O _ - ----------------_------ ---------------Phone ------------------------------------ Address -------- - - -------------- ----�---- ----- - --- - - - - - ------------------- City-=C�---- -- - / , w ----------.License /kf; 5-hone Contractor's N meL(`- Installation will serve: Residence partment House❑ Commercial ❑Trailer Court i❑ , Motel ❑Other -------------------------- ---------------- Number of living units:- ---- Number of bedrooms _ _-Garbage Grinder Lot Size - �__ I_�_____ Water Supply: Public System and name ----------------------•----•------------------------------- -------------------------------------.Private ❑ Character of soil to a depth of 3 feet: Sand'[1] Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe i I MaterialO If yes, type ---------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) '1j NEW INSTALLATION: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK[' a Ti9N"A Size____ _ _ __-_-______.__-- Liquid Depth ---------- Capacity,- - -Via-rl--- gype Pl__L�l--- Material-C11- No. Compartments __-_________________ e' �J Distance to nearest. Well --------- _-----_Foundation __1419----------- Prop. Line------------------ i LEACHING LINE [ No. of Lines --- ----------------- Length of each line_,/A 4___ 'fa a--- Total Length ---------------- 'D' Box __ _ -- Type Filter Material A7_1644--_Depth Filter Material _//9--------------J-.-..._..__---_ r . Distance A nearest: Well ----" --_--___ FoundationZ ------.----- Property Line S------------------- SEEPAGE PIT [ ] Depth - -1________ Diameter -��._-- Number -___ _______________ Rock Filled Yes to 11l/ _ 3 Water Fable Depth ------------------------------------------------Rock Size -lam -----------------•--- Distance to nearest: Well -------- -�'---____--Foundation ------------ Prop. Line ...... ------- In REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date --------------.-------------------) SepticTank (Specify Requirements) ------------------- ------------------------------------------------------------------------------------------------------------- Disposal Field (Specify Requirements) ----------------------------_ --------------------------------------------------------------------------------------•--------------- ------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------- (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." j Signed ------------ ------------------- Owner I Lcl BY ------------------- e ---------------------------------------------------------- Title ---------- ------------------------------------ ------------------ owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �e �� - DATE -__ f�J--r�--•---------•--------- - -------------- ---- BUILDING PERMIT ISSUED ------------------------- = --DATE ------------------------------------------- ---------- ADDITIONALCOMMENTS ------------------------------------------------------------------•-------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ ------------------------------------------------- ------------------------------------------ ---------------------------------- w ----------------------------------------------------------- --------------------------------- - - ------ ----- - --- Final Inspection by: --- --- - - --- ---- --- - ----------------- Date -- .� ---------------- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT l� G E. H. 9 1•'68 Rev. 5M