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FOR OFFICE USE: APPLICATION FO SANITATION PERMIT Permit No. (Complete in Triplicate) ---------=----------------------------------------------- Date Issued ---------------------------- ------------------------- is Permit Expires 1 Year From 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/LOCATII�ON I IS_____ •------------------------------------------------------_(1�`�_____Club---------CENSUS TRACT __________________________ Owner's Name ----- !�) h l` --- Ur 4- Phone Address /�Q �G L� ��--------o�-Qiii�� k4,-kC1V_12?d. CitY7�4?¢` Contractor's Name ---C.R ......�31. Z-15?z __________________________________License # __ _. - --- Phone _L2;_Z3e.Pv(�.,�_ Installation will serve: Residence CX Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units:----/----- Number of bedrooms ---I------Garbage Grinder ------------------------ Lot Size ---------------------- /_C Water Supply: Public System and name _ /11'e ___,01!2Z------w.C-lea......................-------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:V 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,)��jj PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size_ _ J�, �`� ____ Liquid Depth ._!- ............... T Material_i..�_1 No. Compartments .......... Capacity/ 1�-_-- yp l P ----- - ------------ Distance to nearest: Well ________6 -- -------------- ------------ Prop. Line ____ ......... LEACHING LINE [ ] No. of Lines _______ g g ___________ Length of each line___ �� _ Total Length ____7..d________________ 'D' Box ------------ Type Filter Material _'�_7----Depth Filter Material __/_�?..................... .............. to nearest: Well ------�-af_----- Foundation _____/L} l _ -------------- Property Line ._CS .__... --•-- Val- Distance SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number _______________________ Rock Filled Yes '❑ No Water Table Depth ------------------------------------------------Rock Size -------------------------.------ Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ---------------------------•----------------------------- DisposalField (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 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 4 o Wor an's Compensation laws of California." Signed -----an owner --------------------------- Owner BY ------- - -------------------------- Title ----------------------- ------------------- -------------------------- (If other th ) FOR DEPART NT-USA ON Y APPLICATION ACCEPTED BY ---------------------------------- ------- `-----------• DATE ----- "li _ -•-------_--------- BUILDING PERMIT ISSUED ------------------------------------- ------ - --- --- ------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS -------------------------------------------------- ---------------- --------------------------------------------------------------=---------- ---- ----------------------------------------- ------ --------------------------------------------------------- --------------------------------------------------- ------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ -------- _. - --- --- - - -- - - -------------- ------ -- Final Inspection b _ ____________Date __ .�/ SAN JOAQUIN LOCAL HEALT - STRICT E. H. 9 1-'68 Rev. 5M