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FOR OFFICE USE: 'PPLICATION FOR SANITATION PEP'"T ------ -------------•--------- ----- �►�► (Complete in Triplicate) *"W Permit No. -.773------------- --....---------------- ----------------------------- -_.-_------- This Permit Expires 1 Year From Date I Pye Issued co 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: JOS ADDRESS/LO ION _��? ----- -----` ---- •r , '--- - ------CENSUS TRACT ----------------------_- Owner's Name _ :"``'-r_G<tL.J ---------- - ---Phone ------------------------------------ Address ----- -- ------- --- _ __ City � t "c�'•----------- -------------------------------- ------------------ ------------------•-----•---••- - --- - - --- -- - Contractor's Name _.__ ..�✓ "'�' "=-- ----------License # _I3t --- Phone Installation will serve: Residence [tf�Apartment House❑ Commercial ❑Trailer Court ,❑ Motel ❑Other -----------------------------------------•-- Number of living units:------- .--- Number of bedrooms ---->---Garbage Grinder ___________ Lot Size -- - -- -------------- Water Supply: Public System and name --------------------------------------------------------------------•------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy loam ❑ Clay Loam El Hardpan �f 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 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 [ I No. of Lines ------------------------ Length of each line---------------------.------ Total Length ________________------_._.-- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---------..--------•--•-------------------.- Z Distance to nearest: Well __________________ ... Foundation ------------------------ Property Line --------------- ........ SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ----------------- ---------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size ------------------••--•--------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ____......_____---_--- �p H REPAIR/ADDITION(Prev, Sanitation Permit# -------------------------------------------- Date ------••--------..-.-------.------) Septic Tank (Specify Requirements) ---------------------------- ----_- Disposal Field (Specify Requirements) -- --- . .. . .--- - ll- -'=--- -- -#42-�=-------------- z ----------- -------------------------------------- (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 ----------------------- ---------------- f----- -------- .. .._---------- Owner . ,� Title - G'lt '9---GAJ By ....... -------------- l.f__ .___.__ _._ (If other than owner) T _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYr` - =-'"ri ;► ----------------------------------------- DATE _._ BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------ ADDITIONALCOMMENTS _-----------_--- ----------------------------------------------------- ------- ----------------------- - ------------------------------------------------- - ------- ----------------------------------_---------------------------------------------------------------------------------------------- ---------------------- ---- ------------------------ ----------------------- ------------------------------------------:---------------------- ---------------•------------------------------------------------------ -----. . ----------------------------------------------- -- ------------ ------ ---------------------- -----• - ---------------------- a # - 4 `K— ----•-------------------------••-•-----pate Final Inspection by _ .. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M