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t -� .FOR OFFICE USE: APPLICATION FOR,SANITATIO_N PERMIT ------------------------ -------------------------------- �. w . ,Complete in Triplicate) �5��.� Permit No: --�-------`�`�---� ----------------- This Permit Expires Y Year From Date Issued Date Issued ._.S�j-77 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. JOB ADDRESS/LOCATION -- --- v i ------,— ------ --------- - --------- --------------------CENSUS TRACT __-_ Owner's Name --- -- E ------ --------t�` .:- ----.--Phone Address -------------------- ----- ` = ----------------------------------------•-- City _' JR - a. Contractor's Name _-- _ G - ' . k_.Q -- - --7- Phone -43Z!y/:�d----- Installation will serve. Residence)''Apartment House,F Court ',❑ .- Motel ❑Other --- -------------------- - - ----�-A - ---- Lot Size ---- - - - l g '� ,�•_ Number of"li' ng units_____________ Number of bedrooms _____ Garba a Grinder -----------N Wat@r Supp y: Public System and name - ---------------------------------------- ----------- ---�--- --------------- t --: ---Private' W Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ 4SandyeLo'am {Clay Loam` Har dpan ❑ Adobe ❑ Fill Material ________.__ If yes,-type (Plot plan, showing size of lot, location-of.'system i relation -to'wells;`buildings etc nust,be !placed on reverse side.) } --N-EW INSTALLATION: (No septic tank or seepa pit permitted if public sewer is available within 200 feet,) f PACKAGE TREATMENT € ] SEPTIC TANK'[e Size-____. ___X Q__y__7, ----- Liquid Depth __. ____________._ ' Capacity _____ Type t,r I --- Material--_ ask No. .'Compartments --------- �� Foundation E` ._ r Pra Line --�'--•-------- stance to nearest: Well __________ _ p. LEACHING LINE No. of Lines —------------ Length of each ------------- Totbl. Length .r`_�--___-_-__ 'D' Box __ Type Filter Material ___ j'a-_____Depth Filter Material ________+_I1-----------------.------ ..-_ L _- Distance to nearest: Well ______�-_O___-_-__. Foundation _______C_u__.___t_____�.Property Line ________________________ SEEPAGE PIT [ ] Depth __ � ______ Diameter R1f__hC7. Number_ _.-------- ____.....____ Rock Filled Yes No C Water Table Depth -----------------------------------------------..Rock Size ----- -------------------------- Distance --- ---------------Distance to nearest: Well ----------------------------------------Foundation ------- ----- Prop. Line .-------••------------ i REPAIR/ADDITION(Prev. Sanitation Permit# _-__--_-.________ t --------------------------- Date ------•------ --�-• -------:--_•--) I Septic Tank (Specify Requirements) ---------- ---------------------------------------•---- ---------------------=-------:--_-,W -------------,-.--------------------------- _ I Disposal Field (Specify Requirements) -------------------------- --------------------------------------------- --------f------------------------------------------------- l._ -------------------------------------------------------------------------------------------------------------------------------- ------------------ ----------------------------------------------- (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 illtules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: i "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 Californib.",' Signed ---------=----- --------------------------- ----------------------------------.Ow ner BY . Title ---- ---- ---------- ----------------- --------------- -------- --- (If other than owner) / -------------------------- FOR DEPARTMENT USE,--ONLY' --- APPLICATION SE'-ONLY' -"-APPLICATION ACCEPTED BY ( � DATE ---- /-------- BUILDING PERMIT ISSUED -- -------------- DATE ------------------ ----------- ------ --- rADDITIONAL COMMENTS --- ---- - ----------------------------------------------- ---------------------------------------------- ------------ = -----------:----------- ------------------------------------- -- --- - ----------------- ----- - - - ----------------------------- ------------------------•--------------- -------- ------ ---- --------------- t' -- ------------- --------------- --- - -- -- ------ --- -------------------------------------------------- ----pa= Final Inspe -------------------------- ----------------- to a SAN JOAQUIN LOCAL HEALTH DISTRICT y E. H. 9 1-'68 Rev. 5M