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r4- FQR OFFICE USE: f APPLICATION FOR SANITATION PERMIT f (Complete in Triplicate) Permit No. } ______________________ This permit Expires i Year From Date Issued Date Issued -7_-___�_ _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 compliance with County Ordinance No"549 pnd existing Rules and Regulations: i O i DDRESS/'_O._CA710N2X- p �/ y-----U�J/�------ NTRACT ---- -.---.-----•----- - ------------ / lOwner's ----------------Phone - !G Address - 11?0?-e13-------------------•------------------------------------ ------------ City i --------------- Contractor's Named t-/15�---_.-- ` iS ' s----------- ---------License # _/O4 /l-- Phonev__'� � Installation will serve: Residence Apartment House❑ Commercial.:❑Trailer Court ;❑ Motel ❑ Other c Number of living units:-----/--_-_ Number of bedrooms ____Garbage Grinder ------------ Lot Size __; _/% '----r____________________ Water Supply: Public System and-name ------------------------------------ ----------- -------------------------------------------------------.Peivdte�� Character of soil to a depth of 3 feet: Sand�'Lj Silt❑ ,•Clay'❑ Peat❑ Sandy Loam -❑ Clay-Loamy ` Hardpan Adobe-E] 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.) f NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size--------------------------------------------------Liquid Depth ----__-____-_____________- { Capacity -----`------ ------- Type --------------- ' Material---------------------- No. Compartments ------------.......... Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----- ------------------ LEACHING LINE [ ] No. of Lines: --------- Length of each line.---------._.-_____________ Total Length ,________--I........... .`._. 'D' Box ------- __-- Typ Filter Material ----- --------------Depth Filter Material --------------------•--------------'_�'-•. �. Distance to nearest:,Well -------------------------- Foundation ------------------------ Property Line ------------------ _ SEEPAGE PIT [ ] Depth ____-_._.t ______ Diameter ______________ _ Numbe: ----------------____---____ Rock Filled Yes ❑ No'-"c i De _____________________ _ - tl Water Table Depth _ �� ------------------------Rock Size ---'--�---"---------=-------�--- Distance to nearest: Well _______________________'______________Foundation"------r�------ ______ Pro Line.---------------------- REPAIR ADDITION(Prev. Sanitation Permit# ---------------------------------- ------- Date ___________ ----------- _._. Septic Tank (Specify Requirements)�---. r ______-__ - _ _ {-- /s I ��-- -------------�-----------------------�-- - - ---fes 1`-CG�- . -- -------•,.--.. Disposal Field (Specify Requirements} __________ 1_ i'_�' ____ C __._ ___ _�____'_ -------- ------------ .41 # ____________ ____________________________________________________________________________i__!__ ____._______- �' ____________________________________.____._________--- ---- (Draw -_- (Draw existing and required addition on�eve�se 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 liven, sed agents signature certifies the following: y , "I certify that in the performance of the work for which this permit.isAssued, I shall not employ any person in such manner' as to become subject to Workman's Compensation laws of California." Signed - 1-------------- ol - ------------- ----- Owner ----------------- - Title _ G�lsa------- ---------------------------------- f other than owner) ;; 77 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY l.. DATE '3p " /---- ---- --------------------- BUILDING PERMIT ISSUED ----------'�------------------------------------------------------ DATE - ADDITIONALCOMMENTS -------------------------------------==--------------------------------------- ------------------------------------------------------------------------ ------ -------=----------------------------------- ---------------- --------------------------------------------------------------------------------------------------------------------------------- = ----- -------------------- -- Final Inspection by: ` ----- ------ -- -- ----•---------------------Date -------- ----------------------- ----------- SAN ------------ - SAN y JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M '' M.