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FOR OFFICE USE: APPLICATION FOR SANITATIONPERMIT ---------- ----------- -------------------- 7 iy (Complete in Triplicate) Permit No: _--_----- ----------- ---------- /S TSC ___..____.__------- :' This Permit Expires i Year From Date Issued Date Issued __. _._____.- 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 madeincompliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .__lpSfJ_®----- ..____6�AA-V-E -----------n-D-----------------CENSUS TRACT _5775/_.___ Owner's Name - �/� Ez_r2�2a �zt �,�] ----Phone Address --- S-Y -- L -/Z� .L! _ 4!�--------------•--. city l�l/�lk� CCG ,+- - --------•--- Contractor's Name ------- h . _ f2 � / c� �� ` License # -13 / Phone _ -----"- -- '---- ' Installation will serve: Residence [Apartment House-E] Commercial:❑Trailer Court !M Motel ❑Other Number of living units------------- Number of bedrooms -------------Garbage Grinder ------------ Lot Sized'/2g� C� --------------------- Water Supply: Public System and name _____________________ _ ___ _____"__Private ❑ Character of soil to a depth of 3 feet: Sand Silt❑ _ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- (Plot __ ____ _(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septicitank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK[ ] Size-------------------------- --------------------- Liquid Depth -------------------- --- Capacity -------------------- Type ------------ ------- Mater- ---------------------- No. Compartments ---------------•------ i Distance to nearest: Well ----- -- ------------------- ----Foundation ---------------------- Prop. Line .-------------------_ LEACHING LINE d [ ] No. of Lines ------------------------ Le gth of ea line-------=-----------_--- --- Total Length ---------------------------- 90 ' D' Box --- ---""--- Type Filter tenial ------ -------------Depth Filter Material --------------•----- pQ Distance to nearest: Well __ __ Foundation Property Line SEEPAGE PIT [ ] Depth __________________ pia eter __--__- ______ Number ---------------------------- Rock Filled Yes ❑ No � m Water Table Depth ---- ----------------- -------------------•----Rock Size -------------------------------- I -------------- I Distance to nearest: ell --------- -- --------------------------Foundation --------------------- Prop. Line _--_-----__ REPAIR./ADDITION(Prev. Sanitation Permit -------------------------------------------- Date ---------------------------------- Septic -_------------------------------_Se tic Tank (Specify Requirements)I --_._ -----•------- v+ Dispo alp Field (Specify Requirements) -_ ____ --------------------------------------------------- --- ----- - --------------------------------------- ------------ -----------------------------------------------=---------------------- _ ------------ (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 rkman's Compensation laws of California." I Signed --- Owner By &I r �� Title --------- ----------- -------------- (If other than ow erg FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- t +----- --------------------. DATE -- -------------------------------------------- BUILDING PERMIT ISSUED ----------------- --------------------- ------------DATE - -----------•---- -------------------- ADDITIONAL COMMENTS COMMENTS __.____._____- _ --- -" __ --- --------- -------------------------- ------------ - ----- - -- . ------- -------- --- -- Fina Inspection by: -- ----- -------.Date ------------- --- ---- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT a E: H. 9 1-'68 Rev. 5M