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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT y -----------------0, 1 ------------------- - ---"----- (Complete in Triplicate) Permit No: "e Date issued --/:=--__7 _ _ _ __ , - -- ---------------- ;---- _-____ --------- ---- 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 County,Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION - - CENSUS TRACT -�----�--------7---�- --- ------ - Owner's Name ------- ----- -AVI--- --------- -- -V .9-------- 'mPhone Address ----------------------------- __7 7---- Contractor's -------------------------- --.-_-- iI Name ------------------ ------- ( elk—, -------.-<---------------------------.License # -----�_---- Phone ---- � •--.... }} Installation will serve:" ` Residenc-e KApartment House'❑ Commercial :❑Frailer Court N(7& poor r o f f Motel ❑Other -------------------------------------------- �---� Number of living units:------! --- Number of bedrooms _�- Garbage Grinder --""--- Lot Size Water Supply: Public System and name �r ---- --J"(-11t-7 -----------------------------------------------------------------------------Private ❑ Character of soil to,a depth of 3 feet: Sdhd❑ Silt-o-, Clay ❑ Peat ❑ Sandy Loam ❑ Ciay Loamc] ' - ,Hardp an Adobe Fill Material ------------ If yes,type ---------------------------- w - • 4 (Piot 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----7?(_7X- 16y------------- Liquid Depth -� rok� Capacity ,7H7o/ Type ------------,------ Material- � G No. Compartments -- (_-__-_---- Distance to nearest: Well ----- Q-------------------------Foundation ---1-6 Prop. Line LEACHING LINE [V(`�No. of Lines --------- ------- Length of each line--------7A ----.-_-__ Total Length 'D' Box -----l---- Type Filter Material Its-J�od Depth F ter/�MGatterial ----------/�------ i _.._.__._ Distance to nearest: Well -__-"-- Foundation ___ � `------- Property Lne --_ , ....... SEEPAGE PIT [ ] Depth -------------------- Diameter ----- _-__ Number ---------------------------- Rock Filled Yes r❑ No i❑ Water Table Depth ___�------------- - ` '- - -----------------•-------.....Rock Size -----------``---------•------ -- Distance to nearest: Well -----------------------------------------Foundation ------------------"- Prop. Line --------------------_. REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ---------_--------__-----__-_--_--) Septic Tank (Specify Requirements) -------*---------- --•-------------------- -------- --- ---- ---------------- Disposal Field (Specify Requirements) C- ---------------- - - - - ----- - -------•--- ---------- --------------------------------- ---------- --- -- ---------------------- --------------------- --------------J� JTL ------------------------------I--------------------- (Draw existing and required addition on reverse side) l�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 i the performance of the work for which this permit is issued, 1 shall not employ any person in such manner , as to become ject to N( o e sation laws of California." ` Signed --- gt . P --- ---------------------- Owner Y -------------------------------- --------------------------------------- ----------------------------- Title --"-------------------------------- ------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- --- -`-`- ------------------- - ---------------------------------- -------------- DATE _./77_7.77,7 ---------- --- - BUILDING PERMIT ISSUED .. t ' ----- - --------------------DATE -----.y-------------f- _� ADDITIONAL COMMENTS -- -Z- -------------- -— �< -r�----- �-' x ��----- -------- -- - --------------------------------------------------"----------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------- --- --------+ ------------------------------------ Final Inspection by: --- --- ----- -- ---- - --- --------------------------- ---- --- - ---------------.Date f — =- i r ---�-mac--------------------- SAN J AQUIN LOCAL HEALTH bISTRICT E. H. 9 1-'68 Rev. 5M- ,