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FOR OFFICE USE: APP r,� APPLICATION FOR SANITATION PERMIT (Comp to in Triplicate} Permit No. - .SaZ- - ----------- / T Date Issued -- ----------------- - / _---- ' t--------------------_._-____.______--__--_ ='' This Permit Expires 1 Year From Date Issued .I 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. 542, and exis ing Rules and Regulations: JOB ADDRESS/LOCATION . _�•_ _ .- -- .(Lr)t.R-�--- ii. ---.. ENSUS TRACT -------------------------- Owner's Name � --------- - ----Phone ---------------------•-----•---•---- r�-. .acv--- -- ----- - -��------ Address -- ----- city ------------------------------------- ........ Contractor's ------------------ --- Contractor's Na �J �s �_ �._ License # ___ I�..;___- Phone ____________________ .. - 1--- � s-r- -- Installation will serve: Residence�partment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:----/------ Number of bedrooms 3------Garbage Grinder Lot Size _..�---_---.�it----a- -_-_-. Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy,Loom -❑ Clay Loam ❑ + ❑ yes, Hardpan Adobe ' Fill Material ____________ If e r4- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) A NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} ---------------- pp PACKAGE TREATMENT { � SEPTIC TANK Size________________ '�________ Liquid Depth .____________-__..__;____. N Capacity -------------------- Type -------------------- Material----=--------------- No. Compartments -----------------= 4 Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line _-----------.-.._-----} LEACHING LINE [ ] No. of Lines ----------------- ------ Length of each line-__r------ -------- ------ Total Length ---------------------------- }'t ` 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------.------.-.-----------_.. Distance to nearest: Well -------------------:___ FoundationProperty Line --------------------- - f t SEEPAGE PIT [ ] Depth --------------- Diameter ---------------- Number -___._____._________________ Rock Filled Yes ❑ No 1 Water Table Depth----------------------------------------=--------Rock Size -------------------------------- -.Distance ----- ------------------------- L. ~-- «-� —...Qistance to nearesf:,Well _ _-___ ._ __Foundation .'__.___.__._____ Prop. Line ______________________ «„ .,. ,... �. ----�-� is REPAIR/ADDITION(Prev. Sanit tiara Permit#' -------------------------------------------- Date _----------_ ---_-) _ ------------- _ r' � Septic Tank (Specify Requirements) - '�-- - - - -------------.-------------- --,..---------- -------------- ------------------ Disposal Field (Specify` R uire gents) __�__,Q___ _�- ------- ----- -�_ _r__7 ,(�[_,re_ - --- 0-- --- -- �'. - _ L ,------------ ----- ------------------ ------------- ; __..___..__.._ ----______�----------------------------- ------------------------------------------------------------ ,- .' (Draw existing and re aired addition on reverse side) t I hereby certify that 1 Have prepared this application and that the work will be donne 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: F "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 be blect to Workm 's C pensati.on laws of California." I� i Signed - 4- ------- Owner B II t Y - -- Title --------- -------- -- ---- ---------- --------------------------- + - - - - --------- -------- -Fes - - (If other than owner) l F, FOR DEPARTMENT USE ONLY �I APPLICATION ACCEPTED BY W- ------------ -------------- DATE ----------------- i BUILDING 'PERMIT ISSUED --------------------- --- ------- -------DATE -------------•-----------------------------= If ADDITIONALCOMMENTS --------------------------------------- ----------------------------------------------------------------- ----------- ----------------- ----------- ---- ----------------------------------------- ----------------- - ----------- -- . -------------------------------------------- --------- --------------------------------------------------------------------------------------------------- ------------------------------ ----------- -- ------- - - --- - t ---- ---------------------------------------------- ----- ----- - --- ---- ---- ---- - - -- FinalInspection by: -------�U °,- - -------(------ ------------------------------------------------------------------------- -.-Date -----�- --- ------� r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.