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FOR',FFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------- ---------- Permit No: .72_-_5_4__ (Complete in Triplicate) ---- -------------------------------------- ------------ - This Permit Expires 1 Year From Date Issued Date Issued f . 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 ._-- _�__'_K�. -- ---- -- -- Y- -- - - -----CENSUS TRACT -------------------------- Owner's Name --------------- ------ -- -- ------- A `------------------------ -Phone Wr__ ?9?p ----- Address --------- ---------------------------------------- C.,14 Name --------- --- ------••---------- ---------- — �J11''�----- -----License # � Phone 7 4 _`el�----C---r..-- Installation will serve: Residence*partment House-E] Commercial:❑Trailer Court ',❑ i Motel',❑ Other -------------------------------------------- f F 134 r Number of living units:__._ _______ Number of bedrooms:----- __IGarbage Grinder --._-------- Lot Sized x. 3--�-------------- Water Supply: Public System and'name --------------------------------•-------------------------------------- -------------------------------------_-Private Character of soil to a depth of 3 feet: Sand:b Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam:❑ Hardpan E] 4 Adobe `Fill Material ------------ If yes,typ ---------------------------- (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 Size----- ________________________ Liquid Depth ---------------- 6N ---------- Capacity Type 1r- -�f"_____ Material_60--k -G�•_ No. Compartments �" C� _ r 0 r �- -----•-- - Distanceito nearest: Well '`_�0___ '_._________Foundation ---l______.t------ Prop. Line _________t__....... LEACHING LINE No. of Lines --__->�------_-_.__ .Length o �_ f each line-- ---- O-/__.._____ Total Length ,____ !U___�___-___-- �- f f f 'D' Box 1__L�Type4ilter M`ateriarg_�. ---- Depth Filter Material -----/_X-------_----------------------- Distance`to, nearest: Well --- - -17:�---- Foundation _._._l_O`_-f____ Property Line __ _`_ --__._.__ SEEPAGE PIT [ ] ,Depth __ _-__. ------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ ..,,,E / ,Water Table Depth - .Rock Size ---- �` �y Disance to nearest: Well --------- -------------------------Foundation --------------------- Prop. Line ...................... REPAIR/ADDITION(PrewSanitation Permit s# _--_.__..______r_________________• -•:- •Date••:-----�___________ j -----------_ Septic Tank (Specify Requirements) -------`--------------------------------------------------------------------------- ------------------------------------------------------- - Disposal Field-(Specify Requirements) ----------------- ----------------------------.-----------------=- ------------•--------------- -------------------------------- --------------- ----------- --------------------------------------------------------------------------•----------------- ----------------------------------------=------ rYs I (Draw existing and required addition on reverse side) I hereby certify that I have prepared red this application and that e 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 "I certify that in the performanceof the work for which this permit is_issued, I shall not employ any person in such manner If as to become subject to Workman's Compensation laws of California." i Signed ----- ------ --------- ------ --------- ------ Owner ------------------------------------ I BY ----- -- ----- -- ------ ------------------------------------ Title ---- - -- --------------------------------------------------- (If of er n owner) _ -_ __r. FOR DEPARTMENT USE. ONLY _ __ I APPLICATION ACCEPTED BY t -------------------------------------------------------------- DATE - t; ��z BUILDING PERMIT ISSUED ---------i=--------- -- - --`_-.-_ -------DATE ---------------- ADDITIONAL COMMENTS -----------'--------------'- ---.----- ___-•: _. ---------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ______________________________________________________________ _ _ _ ..__ _ -__________.____-__..______ - - _ ______________ _________________________ ______________________ _________ ____ ____ __ ____ ________ ___________- �� _ Final Inspection b ' -------Date ----G � ---------------- } SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M