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FCR OFFICE GSE: PPLICATION FOR SANITATION PEi T - -------- -----�--�---- (Complete in Triplicate) Permit No. .. ._..�. ------'---------------------------__ ------- 1 _ ----- __ _ _ __ __ This Permit Expires 1 Year From Date Issued Date Issued .. ....L:.1!/ 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 complian a with County Ordinance Nqr 5499 and existing Rules and Regulations: r JOB 3S/LOCATION _?f��...... s L2.. • ` �� 7,05 --CENSUS TRACT y__. .'... Owner's Nape C_. r- '`4 - ------------- ;'---- ----- Phone - O..G -s 3-- Address .0-01z, r �i�/ City -- 'C s ------------------ ----- Contractor's Name -_..: �Z/! +!� `- - - _._-_..-_____._-._.____License #o rlJ --Z Phone Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 .. Motel ❑Other ----------- --------------- --------- Number of living units:....- ------ Number of bedrooms _....Garbage Grinder ---------_ Lot Size --------------_--------- Water ._._-_--_--__.__Water Supply: Public System and name ------------------------------- -_ -----------------.--------- --------------------------------------------Private [ r Character of soil to a depth of 3 feet: Sand E] Clay ❑ Peat E] Sandy Loam E] Clay Loam 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ` i 11 PACKAGE TREATMENT [ ] SEPTIC q TANK lq/,— Size._ .p.._ �,vQ� ---.� Liquid Depth __4_.._.______._. ------------------ Capacity _�_ l._ Type Sr-7_____ Material_4--- L:C. No. Compartments . -------- ....... stance to nearest: Well .tea_`.__---- .--.___Foundation _ . _AQ..�------__ Prop. Line _--X--- _ /____ --- LEACHING LINE [ No. of Lines __ ---------- Length ofeachline__? -- --J6-Q. Total Length 'D' Box .... - Type Filter Material 14�_ epth Filter Material _ ---------.____...- i _ s ! r Distance to nearest: Well -1��.._.-___._ Foundation ._/0----._-______ Property Line ....:..........._..._._ r p� SEEPAGE PIT [ Depth _/.Y_._._.-...._ Diameter ( r _/..� Number ..._.__._/._."./i Rock Filled Yes No ❑ Water Table Depth ------- Q-------------------- -"---Rock Size __�2: --------------------- -1 11 Distance to nearest: Well _--/,V-_/.-----------------------Foundation ...... Prop. Line .-..gip.......... REPAIR/ADDITION(Prev. Sanitation Permit# .-_..............___.__._____.____.___ Date -----------------....... .........) Septic Tank (Specify Requirements) Disposal Field ,(Specify Requirements) ----._ ------- --._-l! ,+-5----- QItJ.B.ER ------ tlflr S P2 rC 5'Y5 WA5 LNSTEt-�(-1�vD Hy :_..C1cs/A/..RIS►� PF,.eID►-r(C-- AP-PSI-�� `�'.RPPRQ.uA c... 19�-- V�F.N--�---------- - - - ------- ----- (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 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 _ 1 ` (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ._'I-(.4pp --------- - -(6�!�yy.....__-------------------- ---------------------------- DATE - - -Z-- -- - --------- BUILDING PERMIT ISSUED ---------- -- --------------------------------------- ------------------------------------ -----DATE -----------..-----------.---------------- ADDITIONALCOMMENTS ----- -- ------------------------ ------------ --------------------- ----------------------'------------------------ ------------ - --------- - ----------------------------------------------------------- -------- -- ------- L - - - - - - - - - ---- -------- --- ---- -------------- ------------ - -- �. --- --- -- - ------- -- ------- -------- - - -- ----------------- --- - ------ --- - - Final Inspe ------ - - ...- --- - -- ------------_Date . - �-}: ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M