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I FOR OFFICE USE: " - APPLICATION FOR SANITATION PERMIT ----------------------------------------- (Complete in Triplicate) Permit No. . 7-_--_l6'� ---- ----=-------•--------------------------------- ---- -_._-____,________.____.______________________________ This Permit Expires 1 Year From Date Issued Date Issued� _ lC 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/LOCA? ON .- --------- - ----�. -- ---'----------- -------- ---- ---------CENSUS TRACT -------- Owner's Name .. ---------------------'''--------------------------------------- ------Phone --.--------------------------------- ! ` c E I Address -------1-�i2�._ t/ -vG__ .- ' --------- Cit Y -�- �� I Contractor's Name . �,q � i ------.License# X3,9_x_ PhoC_ _64-= _W) Installation will serve: Residence [/Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other _ Number of living units--------(_ Number of b drooms __ Garb e_Gr•inder._ ---Lot.Sizey__/A'Q ------------------ Water Supply: Public-System and name ----- --------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Sil Clay F] Peat❑ Sandy loam LTJ—CI'ay Ceara'❑ Hardpan ❑ Adobe ❑ 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.) NEW INSTALLATION: (No septic tank,or see ge pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT f ( S ` [ ] SEPTIC TANK'[ Size _,(_ _ - - ----- Liquid Depth ------------- Q111 Capacity .1. _°Q-- _-- Type d Material_ y------ Ni6. Compartments --•----_---•-.__--� 1 f Distance to near st: Well _-----____J�QP_______---------Foundation _____Gv__ ____--___ Prop. Line __- ------- LEACHING LINE No. of Lines _____ g / ® �.___ Total Length ----- 'D' -_ [ l -------�-- -- Length of each line____________ _ ____ 'D'*Box>___ -__.___ Type Filter Material ---4__�--------Depth Filter Material ___l _��________________�. ....... � - '" ' E Distance to nearest: Well ______._-i_�p=_____Foundation ______-_�-n_________ Property Line. _._____.._.-__ . [ Depth �y_-- _-- mer a_r[_w__3..Number,.--=--_ ,- ------_-- Rock Filled Yes No Water Table Depth ---- 7-Q-- - -------------------.-Rock Size -------------------------------- i - -Jr a Distance to nearest: Well ----------/ _4_____________________Foundation '_.___ _a_______- Prop. Line _____; q ............. REPAIR/ADDITION(Prev. Sanitation Permit# 5 1-------------------------------------------- Date ------------- -----------------._-) i Se tic Tank (Specify Requirements) W ----------------------------------------=------ -----------------------------•--------------------------- DisposalField (Specify Requirements) -----f-------------------------------------------------------------I---------------------------------------------------------------- < ---------- --------------------------------------------------- ------------1---- ------ -: ------------- ------------------------------ -------------------------. ----------------I--- --- --- --- -------------------------------------------------------------------------- ---------------------- ------------------------------------- - ----- (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 Son 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 -- -- , Signed ------ ----------------- ------------------ Owner --- ----- - -- BY --------------- - ----- Title -- (If other than owner) FOR-DEPARTME T USE ONLY .. „. APPLICATION ACCEPTED BY -- -- ---- - -- ---- ---' ------------ ---------- __ -- DATE (_----------------- ------ BUILDING PERMIT ISSUED__. -. � �` � DATE ------------------------------------------- ADDITIONAL COMMENTS _._� ___ ______ _ __ '�' = ----- ---------�-y--------------------------------------------------------------------------- _ j --------------------------- ----------------------------- -------------------------------------------------------------------------------------- -- ------------------- ----------- ----- - - -- ---- -- --- -F------------------------------------------------------------------------------------------------- ---------------------------------- ----- ----------------------------------------------- -------------------------------------------------- -- Final Inspection by: ----------------------------------- --------------------------------Date - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M ,