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r FOR OFFICE USE: � � APPLICATION FOR SANITATION PERMIT ----- -- --- ----------------- ---•-------------------- Permit No. - = (Complete in Triplicate) ------------_-----------------_---__---- This Permit Expires 1 Year From Date Issued Date Issued _- `1_7- _ 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 wiittthh�Counyrd once o. 549 and existing Rul s.,and Regulations: JOB ADDRESS/LOCATION _-,t✓" � _-37 fa/9'_ _ - _�-�-( --Eff -----CEICJS TRACT -------------------- Owner's Name --------� - -------� _ s ------------------- - - -- -- Phone Address ----- - /-914—P------ ------ /,� / --- ----------------------------------------- City ' 12- f-------- -------------------------------------------- Contractor's - - ---- ---- ------------------•--Contractor's Name /<,:I,.?74—�> --- �A0 A--e ------------------------------- -------License #��':t`��'= Phone jole4K:4 .�4/------- Installation will serve: Residence%Apartment House�❑ Commercial ;❑Trailer Court i❑ ``; Motel ❑Other ---- --------------------------------------- Number of living units:---/----- Number of bedrooms __.Y----.Garbage Grinder My--- 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 W�'"- 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.) W� NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) f + PACKAGE TREATMENT [ ] SEPTIC TANK'[ij Size__ _}�__1_ -- _�_____________________ Liquid Depth _ y-_-__-___________ y) k Capacity -/Z,0,0 Type X;4-�-1-W;� Material�V/7-e--!_____ No. Compartments ___ - °` ---Foundation -- ------------ Pro f ------ ------ Distance to nearest: Well _____�_�___________________ p. Line LEACHING LINE __._No. of Lines ` Total Length {� �---------------- Length of each line---,/f�.f.� !�-I��-------------- 'D' Box _IIS_ _ Type Filter Material / �eZ//, epth Filter Material 1/_ ---r____________________I--------- / f Distance to nearest: Well f�-f------------ Foundation --14---------------- Property Line ------------ SEEPAGE PIT [ ]� Depth -~_---_ Diameter ,�z� -------- Number ...... F----------------- Rock Filled Yes No Water Table Depth ---------f -------Rock Size Distance to nearest: Well --------111111 /7-------------------Foundation __. f-f_f.___ Prop. Line ...... REPAIR/ADDITION(Prev. Sanitation Permit# -------•------------------------------------ Date -----------:---------------------__) Septic Tank (Specify Requirements) ------------_-----------------------------------------------•- Disposal Field (Specify Requirements) -------- ------------------------------------------------------------- ----------- -------------------- ---------------------------------------------------------------------- --------------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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 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 Workman's Compensation,laws of California." Signed -------------------- --- ------- ------------------------- Owner ' PP Title _... L'iL . i3Y -------------------------- (If er than owner) FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY .--- ----. DATE ' ------ ----------------------------- BUILDING PERMIT ISSUED ------------------------------------------------------------------------------------------_- -________------DATE ---------------- ---- ------------------ ADDITIONALCOMMENTS -------------------------- --- ----------------- -------------- ---•---- --------------------------- ------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------- --- ----------- -------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- r - - - - - - - - =------- Final Inspection by: - --------- � ------------------------------- Datej SAN JOAQUIN LOCAL.HEALTH DISTRICT 1 E. H. 9 1-'68 Rev. 5M, r i