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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - ------------- -- ---------------- - _.?_�' (Complete in Triplicate) Permit No. --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued _Z___ _ _�! 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 andexisting Rules and Regulations: JOB ADDRESS/LOCATION ._-.6-2-G-- '--- -----4--47-tli-I?D -__._._0f?//+ ENSUS TRACT -------------------------- Owner's Name J-te ev2_------AI f-X�_ 14�f�/_A/4)------- ----------- -------Phone ------------------------------------ CI ` 1 � 7 �--y Address ---` � --------c-�-------� �rK'� --------------- Cit �1`p G!l�es-c Contractor's Name __.._ ._l=_,___ _� _l -________________.________.License --- Phone _ ' ___ Installation will serve: Residence ❑ Apartment House-NkCommercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units:------------ Number of bedrooms ------------Garbage Grinder ------------ Lot Size _____________________________________ Water Supply: Public System and name ____ � _ `f_rZ .- �2- fiCL Lf _?� '_t"�__________________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 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,} 1 PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size----------------------- - --------------- ------ Liquid Depth -----------.__._-._-_.---- I�• Capacity - ------------------ Type -------------------- Material-------- ------------- No. Compartments -----------------... Distance to nearest: Well ------------------- ---------------Fo dation ---------------------- Prop. Line ------------- LEACHING --.--- ---..LEACHING LINE [ ] No. of Lines ------------ ---------- Length o each line__ _________________________ Total Length ---_._-____-__-- _..._....__ D' Box Type Filter Material epth Filter Material --------------------------- Distance to nearest: Well _______________ _______ Found ion __.____._.____--__--_--- Property Line ___-_______.._____...... SEEPAGE PIT [ j Depth Diameter ____ __________ Num er .__._.____---_--__--_------_ Rock Filled Yes ❑ No ❑ Water Table Depth --------------------- -------------------- ---Rock Size -------------------------------- . Distance to nearest: Well ___________ ___________________ _ _ ____Foundation --___-__-_-_- ------ Prop. Line _________..__._..__.. REPAIR/ADDITION[Prev. Sanitation Permit# -------------------------------------------- Date -----_--------------.------------_) SepticTank (Specify Requirements) --------------------------------------------------- -------------------------------------------- -----------.•.--------------------- D ) ----� , ' � ` G'= ------- - -_ 1_Q _cf------- ` t-- 1vle__ ' -�� P------ -- ------ �C ------oa_s � ---------------------- ---------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ ----------- ---------- (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. Horne owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Work n's Compensation I ws of California." Signed - ------------------------4-- ------------------------- Owner By -------- C- ---Y---- -'- --- -- -------- ----- ------ --------------- Title ---- ------- -------------------------------------------------- (lf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- A ------------------ ---------------------------------------------- DATE "�' .3-_2f�. --------------- -- BUILDING PERMIT ISSUED -- ---- ------------------------------------------------------------ ----------------------DATE - ADDITIONAL COMMENTS - -- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- ----------------------------------------- ------------------------------------------------- - - - ---- ------- - - - -- -- --- --------------- -- ----- ----------------------- FinalFinal ------ ---- -- - - ---------- Inspection by: ----------- _ Date - _-_*3 —">_'-^------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M