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FOR OFFICE USE: I P 0ol-1 Red wtwc YW O APPLICATION FOR SANITATION PERMIT // ----------- Permit No�� __2_6 k (Complete in Triplicate) _______________ This Permit Expires 1 Year From Date Issued Date Issued 10.--__F' .0 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 .---/�//-zyeQvve,,Qd-----P,'-/ '� ----------------------------------CENSUS TRACT .------------- ----------- Owner's Name /'Y A.t'/� ,� ,�'r d ' --r--- -------Phone SJ J- � ----- Address 207,00-0/f1 _.�-.�--r�-/y- / Qe_.�QZ91i3,X -------------------- -- City __f' a2 -_ ✓-------------------------=------------------------------ Contractor's Name ----------------------------aaa---------------------------------------__License # ---------- ------ Phone .............................. Installation will serve: Residence 2-KIPartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other-------------------------------------------- jo Number of living units:________ Number of bedrooms _____!_____Garbage Grinder __'"----- Lot Size ______ j��_____________________ Water Supply: Public System and name ---Gmi"_:---�41-:5ewl-------------------------------------------------------------- ..........Private❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe,E?,, 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 f ] Size------------------------------------------------ Liquid Depth .._____________---___-___- Capacity -------------------- Type ------ Material--------------------- No. Compartments -----------------•---- Distance to nearest: Well ____________________________________Foundation ______________________ Prop. Line ...................... r, LEACHING LINE [ ] No. of Lines ------------------------ Length of each line________________________ Total Length ,_____--___--_.-___-----_._. 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 i❑ Water Table Depth ------------------------------------------------Rock Size ------------•------------------- Distance to nearest: Well _________________.___________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------71------------------ Date ----------------------------------) Septic Tank (Specify Requirements) ----------*_00-----a-e.. ll--cf------------------------1---------------------------------•-------------------------------------- Disposal Field (Specify Requirements) ----I )�_�C6...f?'f----�0r----t ��_ e---------------------------------------------------•----------- ------------------------ --------- - __ (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, 1 shall not employ any person in such manner as to become 'ect ��an laws of California." Signed' - -------------------------- Owner By ------------------------------------------------------------------------------------------------------ Title ----------------------------------------------- ----------------------- (If other than owner) FOR DEPARTME T U O LY APPLICATION ACCEPTED BY-------------------- ------------------ ------- -- - --------. DATE --- BUILDING - �4 BUILDING PERMIT ISSUED ------- ----------- --------------------- -- DATE ------------------- ---------- - -- - - ----------------- - ADDITIONALCOMMENTS --------- ----- ---------------- ---------------------------------------------------- ------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- --------------------------------------------- --------------------------------------------- ------------------------------ ----------------------- ------------------------ ---------------------------------------------------------------------------------------------------------------------- f,f_ __1- -`--=------- Final Inspection by: ---------------------------------------------------------------------------------- r ✓1-�-i Date --- -- SAN JOAQUIN LOCAL HEALT4/6ISTRICT E. H. 9 1-'68 Rev. 5M