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i FOR OFFICE USE: 9P 4-w 2- APPLICATION FOR SANITATION PERMIT - Permit No. ---------- (Complete in Triplicate) .......... ---------=-------------------------------------------- -- // ____,_____-__________________________________._ This Permit Expires t Year From Date Issued Date Issued -_ --`-.�-- 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 and existing Rules and Regulations: JOB ADDRESS/LOCATION ._ __�_ _____ L1CI_!j _ _ s9_/ __�F` _ _ _____ `'� -� N "� _ E<Y _ _ CENSUS TRACT Owner's Name --------- �'�oq/4 is Npcao--------------------------- --------- -------Phone ------------------------------------ Address -- ---- .°l�C�C7d -------- SS.n ---SJ-----------------------•--. Cit 7-`e3--`- - Contractor's Name _____ A/V-n_a_ Y___''(__�/'____-______________________License # - �`'_ _ Phone Installation will serve: Residence []'Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other -------------------------------------------- ,gr Number of living units:_____1___ Number of bedrooms ___I......Garbage Grinder _NO___ Lot Size ---------------------------------------------' a Water Supply: Public System and name ---------f-'-''- -C°---------------------------------------_-------------------------------------------Private❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay EK 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,) PACKAGE TREATMENT [ ] SEPTIC TANK M Size----- --------------- Liquid Depth -----�/................ Capacity )Z_40_______ Type p?'�' _� %TMaterial___Cf ��____ No. Compartments -_?�............... Distance to nearest: Well __________________________________-Foundation ____ ------------ Prop. Line ---j-7---_._.----_ LEACHING LINE [ ] No. of Lines ______ ___________ Length of each line---------9a------------- Total Length ,_747------------------ O 'D' Box ____________ Type Filter Material ____________________Depth Filter Material -------------------- ....................... Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ----- .................. SEEPAGE PIT [ ] Depth _ ____ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 WaterTable Depth ------------------------------------------------Rock Size -------------------------------- .._ Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prey. Sanitation Permit# ____________________________________________ Date ----------------------------------) SepticTank (Specify Requirements) ----------------------------------------------------------------- --------------------------------------------_--------------------------- DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 Workman's Compensation laws of California." Signed -- - A/>r T'l a e y `f� Sa Gy'------------------------------ Owner ---'- ------------ w- - BY ----------- - TitleGrLGG ------------------------------------------------- n ner) FOR DEPARTMENT J14SE O Y APPLICATION ACCEPTED BY ---------------- ---- --- DATE -- . �. ------ ........... BUILDING PERMIT ISSUED ------ ------------------- = -DATE ADDITIONAL COMMENTS ------------------------------------------------ - -- --------------------------------------------------------------•----------- ------ -------------------------- ---------------------------------------------------------------------------------- ----- --------------------------------------------------------------------------------------------- ------ ------------------------------ --------------------------------------------------- ------------- ------------------------------------------------------ -_ ------------------- Date 1----------------------- Final Inspection by - --- ---------- - SAN JOAQUIN LOCAL HEALT TRICT E. H. 9 1-'68 Rev. 5M G x.