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a Fen OFFICE USE: �. APPLICATION FOR SANITATION PERMIT -- / '=/--------- � .n - ------------------ ---------- �d � �� (Complete in Triplicate) P+srmit No. __ ______--_ � ---------=---------- �� ---.---------- _._________ This Permit Expires 1 Year From Date Issued I]ate Issued _a �� Application is hereby made to the Sankaquin 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: I ION % . o / -------- CENSUS TRACT -------------------JOB ADDRESS/LOCATj ' I Owner's Name __ /.�f. &P------i 1/f Phone Address --. --- ---,:�---------------------------- --- ------------------------- ----------------. City fi -- ----------------------- --------------- ' Nm � _ Contractors _a j Installation will serve: Residence [Apartment House 10 Commercial ❑Trailer Court ;❑ Motel ❑Other �------------------------------------- i Number of living units:----/---- Number of bedrooms _ ___.__Garbage Grinder Lot Size -744.1.44.0_`____________ Water Supply: Public System and name_ J, l� 'f� "— _________________Private El Character of soil to pth of 3 feet: Sand'❑ Silt E] Clay E] Peat E] Sandy Loam •❑ Clay Loam :❑ Hardpan ❑ Adobe Fill Material ------------ If yes, type ___ ________________________ {Plot plan, showi pg size of lot, location of system in relation to- wells, buildings, etc. must be, placed on reverse side.j' NEW INSTALLATION: (No septic.tank or seepage pit permitted if public�sewer is available withiin 200-feet,] �, G PACKAGE TREATMENT [ ] SEPTIC TANK'X Size--- ..�� ___________________ Liquid Depth --.-___._..,______x - -�.. s Capacity� __,___ Type _ Material_ef-p z ___ No. Compartments -------- ------ Distance to nearest: Well -_____-^----'----'________________Foundation __Ax--------------- Prop. Line _lam_--_.___.-_V1 LEACHING LINE [ No. of Lines ------------ j g , --------------- Length of each cine-__-- :��'___------ - -_ Total-Length th .`��__________-_--- 'D' Box � Type Filter Material _l &*�bepth Filter Material If-*P------ _- ______-_ � > pistanc toy arest: Well ____'`_--_________ Foundation __ ---------- Property.Line _sa0.___________-. ...'t SEEPAGE PIT { Depth _ - _0------- Diameter _ ----- Number - ______ Rock Filled Yesk No i❑��' Water Table Depth ' Rock Size / Distance to nearest: Well ________________________________________Foundation A ------ Prop Line _47............ REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------Z---------- Date -------.--------------------------1 Septic Tank (Specify Requirements) _ __ ___________._. - ;__ ------------------ -------------------------------------------- ------------------------- 0 to Disposal Field (Specify Requirements) - ---- ---------------------- ----------------------- ---------------------------------- --------- I------- -- ------ I ------------------------------------- ----- -- -------- --- --- -- ------ -- - ------ -----------------t ----- (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--Workmbn's•Compensat' n.iaws of.California." Signed ------------------------------ --- ----------- = -----------------. Owner By ---------------------------------------- -------- ----------------- Title --------4411-1,zlelt--------------------------------------- (If other th owner) FOR DEP TMENT USE ONLY APPLICATION ACCEPTED BY . -- --- ---------------f-----�e--------. DATE -------- 71-------------- BUILDING PERMIT ISSUED -------- - ---------------------------------------------------------------------------�` --------------DATE --------------------------------- --------- AD,WIONAL CO�MENTS ------------ ----------- -- ---------------------------------- ----- -------------------------------------------------------------- ---- -----------27- ------047 ---------- 0$------Q------ -----------------------------t4t--------------------------------------------------- ------------- - -----------------------------C.--------------------------------------------------------------------- ---------------------------- i --------------------------------------------------- --------- ---- -- Final Inspection by: ------------ f ----------------.Date --- ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 94.1"%g'Re-v 5M