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FOR OFFICE U E: �/` APPLICATION FOR SANITATION PERMIT _ y '1 (Complete in Triplicate) Permit No: _- (-7 .D _________________________________________________________ This Permit Expires Z Year From Date Issued Date Issued n 14 t 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: ------5'/_/l/�,_�11�'_ --- -------------- - JOB ADDRESS/LOCATION .__I�_��__.__,,,; _ CENSUS TRACT __________________-__.___. Owner's Name ---/-Vd.emv. lv-----_ZXe?_5_ON---------- -------- ---- --- -Phone ------------ ------------ Address r- I�. Cityrl�l�J - ------------------------- ---__----.License � PhoneContractor's NameT '-�jr _--- Installation will serve: 'I Residence jg Apartment House,E] Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:.___ ___i___ Number of bedrooms _2----Garba e Grinder /✓v Lot Size Water Supply: Public System:and name ------------------------------------------------------------- -r'--------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay .❑ Peat❑ Sandy Loam ❑ Clay Loam_❑ "9 II Hardpan ❑ Adobe_jo 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.) t NEW INSTALLATION: (No (septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK V p [ ] �� _ q p Size---- ---- ---�-x�=�------------ - - - Liquid Depth ---ST------------------ J Capacity/ ©ljl_ Type ,�1� aterials;��' No. Compartments .._ ---------- 00 Distance to nearest: Well __________, r____________Foundation ....1/ ------__ Prop. Line ___155--__`---------- LEACHING LINE No. iof Lines ____.__/______________ Length of each line----i/1"_` ------ .---- Total Length .._� _C�-__'__.__-_--_ 'D' liox-0/0---- Type Filter Material 64Z% C____Depth Jilter Material _____1____________________________________ nce to nearest: Well _____,�C�_�____.__ Foundation _ p_�__-______ Property Line. _ ______________ SEEPAGE PIT Depth -------- Dista h .-_.� ��_-___ Diameter �-�_______ Number .____�___/--------------- Rock Filled Yeses] No i❑ p r v Water Table Depth -- -----------------------------------------Rock Size --1__ �,�----------.__. Distance to nearest: Well ______l P 0______________________Foundation ------- Prop. Line _____ __.___.. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------" Date _--------------------------------_} Septic Tank (Specify Requirements)k------------------- ------------------------------------------------------------------------------------------- ------ Disposal Field (Specify Requirements) ---------- ------------------------------------------------------------------------------------------------- ` ----------------------------- - ----------------=------------------------ ' -------------------- -- -------------- -- 1� {Draw existing and required addition on reverse side) f 1 hereby certify that I haveprepared 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 Compe ation laws of California." i * t Signed --------------- - ------ ------- ---- ----- Owner ------------------------------- Title ----- -------------------------- LL, '(If other an owner) FOR DEPARTMENT USE ONLY APPLICATION PP(CAT ON ACCEPTED TBY�` -------- --------------------------------------------------------------------------. DATE ----- �' -�1 ------------------- BUIL ------------------------------------ --- ---DATE ADDITIONALCOMMENTS 1� --------------------------------------------------- -------------------------------------------------------- -------------- ------------------ �i ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------- -----------------------------------k--------`-%'=---------------------- ---------------------------------------------------------------------------------- II - ---- ----------- ------------------------------------- Final Inspection by: --� i ------------------------------------------------------------------------------ -----------Date ---------=--- ---------------------- ,. uL SAN JOAQUIN LOCAL HEALTH DISTRICT -� E. H. 9 1-'68 Rev. 5M, G 1 � �