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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------- ----- ------------- cL r (Complete in Triplicate) Permit No. eel -Z -------- -------- ----- ----------------- Date issued ----- ------------ -_ _ ?-------_-_ - This 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 Co my Ordinance No. 549 existing Rules and Regulations: JOB ADDRESS/LOC N -Y�i- -- ----- '''�^t---^ Chi .. --CENSUS TRACT ------ -------------------- Owner's ----------- -. -----••--.Owner's Name :--------------- ----- --- --------Phoned Address ---- --� ---------------=--------------- ----------------------------. City --------- -- ----------------- ------------------------------•--•---•------ Contractor's Nam -'----- - 1- - -r.�--,-- .License # Q��`--- Phone Installation will serve: Residence t-?CApartment House,D Commercial ❑Trailer Court i❑ Motel ❑Other -----nn- ------------------------- Number of living units:----I------- Number of bedrooms _�t-----Garbage Grinder - ---------- Lot Size ------------ Water Water Supply: Public System and name -------------- ---- ----------- ---------------------------------------- ---------------------------------------Private 01 - Character of soil to a depth of 3 feet: Sand❑ Silt j] Clay ❑ Peat❑ Sandy Loam; Clay Loam E] Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- (Plot __________________________(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 sewerisavailable within 200 feet,) W PACKAGE TREATMENT [ ] SEPTIC TANK:K y' - e.- __� _ _............-------- Liquid Depth - -- -•1-1---. ------ Capacity Type IDOL- � Cate .... No. Compartments - s--- ------------ 1 Distance to nearest: Well �._�f - ---------------------Fou dation __ _l�__ _____ Prop. Line ______ ________._._ �., . LEACHING LINE No. of Lines ___2- _________-.__ Length of each line-. 0— Total Length --------/i ----. - �.�+ r D' Box __._.lt--___ Type Filter Material s f&4- -_Depth Filter Material ---1-7. ........................... ... Distance to nearest: Well�12___; u3cation ---,�- -_:._.__F? Property Line ........ ............ SEEPAGE PIT [ ] Depth -------------------- Diameter -------------,---- Number ------------- `___._: Rock.-Filled Yes ❑ No iQ Water Table Depth ------- ------------------- �--7- ,-----Rock Size -------------------------------- Distance to nearest: Well -----------------------t__-_,.__---------Foundation -------------------- Prop. Line --------..____.___ ' REPAIR/ADDITION(Prev. Sanitation Permit# ....-_.,------------------------------------ Date __-_-.--_-.----___-_-__--_--_-_-_.] Septic Tank {Specify Requirements) ---------------------_---=----------------------------'------------------------- ------------•--------------------------------------------- Disposal Field (Specify Requirements] - -------- --- -------- ------ i } --- - - r --------- --------------------------------------------------------------- - ---- --- ------ ----- ----------------------------------------------------------- ------------------------------------------------------------------------- -- ----- ------------------------------------------- ----- (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 t 's permit is issued, I shall not employ any person in such manner as to beco su lett to orkm n's �TT tion laws California." Signe i r '�'� T--- ilk M- BY --- - - - - ------- ---------- itle j (If other than owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...___:__ ---------------- DATE ----- 3�M BUILDING PERMIT ISSUED ------ --- ------------ ----------------- ---------- ---------- ---- - —DA E ----- ------ --------- ADDITIONAL COMMENTS --- -fid- -6.,P-- -- - ----- ----- ---- .--- - --- --------------------------------------------------- - --- -- --------- ---------------------------------- -- ----- -------------- --- -------- - y ----- - �-- ----- ----- - - - - - - bra✓�fi -- --� ,p ------------------------------- - ---- --- ----- -- ------------------------------ ------------------------------------------------------------ ------- ---Date �.�o -��yf'_(- Final Inspection by: ---------- ------------ --- --------------------------------------------------- i SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M