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FCR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------ Permit No. " (Complete in Triplicate) -- ---------=---------------------------------------------- This Permit Expires 1 Year From bate Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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/LOCATION ------ p�] __7f__/ t•Ca _N _17Jf C7 -----CENSUS TRACT _-._.________.___.______ Owner's Name .__�/f-------/S e,?_11... ----•----------------------------------------------- - -- - Phone ---------------------------•-------- Address ------ 5 -GC<�_.Gsc 'K4 --------------------------------------------- City ��C.r J----------------------------------- i ________.License #� '�-f� '_ Phone _ 46p� ' Contractor's Name �+��1�€ -------------------------------------------- --- -- - -- - "�---------- -----------•- Installation will serve: Residence>(Apartment House❑ Commercial ❑Trailer Court 'F] Motel ❑Other -------------------------------------------- f ` ' Number of living units----/------ Number of bedrooms __,_____Garbage Grinder ____._____ Lot Size _!©o____�__w_Q___l___________ Water Supply: Public System and name -----(3-- fQ �--- --'-------------------------- -------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ "Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobex 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 [ ] Side_________________________________ Liquid Depth __________.__-_____-_. Capacity -------------------- Type --------------- ---- Material----------------- No. Compartments ------ --------------- Distance to nearest: Well _________________$--------------------Foundation ---------------------- Prop. Line ________.___-_____-___ r LEACHING LINE [ ] No, of Lines ________ __------------- Length of`egch-line_____..-7p______.___-__ Total Length -----.�________.._.___ 'D' Box Z _-�s}Type Filter Material AX _-'Depth Filter Material ____- - --_----________________ Distance to nearest: WellFoundation __/ --------------- Property Line -----* ______..__.__ . SEEPAGE PIT [ ] Depth __. - -_____-_ Diameter -__ _.____ Number ----------/__________-�__ Rock*Filled Yes No i❑ ilf►ST�� Water Table Depth -----------1;�p-�-----------------•----.------Rock Size ---2, x Distance to nearest. Well _-._I 'srrs, -- -----------------..Foundation' ---P------ Prop. Line ____ ......... REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) SepticTank {Specify Requirements) ---- ------------------------------------------------------------------------------------,-----------------•----------------- ........... Disposal Field (Specify Requirements) ---- /____ _____/=___ cl ______________ -------------------------------------------------------------------------------- ---------------------------------- ----------- ------- ---------- -- ------- ---------- ------------ -------------------------- ---- ------------ -- - - - ---------------------------------------------------------------- - (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 becom"bl�� ect to Workman's C pensati.on laws of California." Signed 3 = Owner BY (If--- --of e-- --r than owner) - Title ---- -- ------- ---------- ----- ------------------- OR DEPARTMENT LISE ONLY APPLICATION ACCEPTED BY ------ ------------- DATE 5��-/--- =72— --------------------------------------- BUILDING PERMIT ISSUED ----------------------------------- -DATE ------------- ----------------------------- - - -- ------------------ ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------- -------------------------------------------------------- ----------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- . ------------------------------------------------I--------------------------------------------------------------------------------------------------------------------------------------------------------- ---- ------ — ----------------- Final Inspection by: -- __-- _ Date -----_�S__--`�--"'�------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M C�