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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- ----- ---------- i Permit No: _.7------------_-- ---------- "� 7 (Complete in Triplicatel ` ------------------------------------------------------- �� a� �'--7 ! ` ' This Permit Expires 1 Year From Date Issued bate Issued ___________________ Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549.and existing Rules and Regulations: l3"coff' 4F /1400116f .ho e, JOB ADDRESS/LOCAT N . �} �t---p--- -------CENSUS TRACT ---------- ---- Owner's Name (Ole"r tC � �� Phone R3r © --- ---- - ---- Address 1 - �Q,,,,//-,,ff fce �a _G City ------------------------------------------------------ �J qq� � � 1/ Contractor's Name _�Q/__`,+' G- License # 7-.; 1 Phone el Installation will serve: lResid Apartment House-E]..Commercial ;❑Trailer Court ,❑ s Motel ❑Other ---- --------------------------------------- e Number of living units_____________ Number of bedrooms ______Garbage Grinder ----------- Lot Size _U-__-'�____-----.- Water Supply: Public System and name -------- ---- -------------------------------------------------------------- '------------------------Private f i Character of soil to a depth of 3 feet: Sand' Silt❑ Gay E] Peat ❑ Sandy Loam ❑ Clay Loam :❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ----'------------------------ (Plot plan, showing size of lotJ 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,) LlI PACKAGE TREATMENT [ I SEPTIC TANK'[ Size- ' ---------------------- Liquid#Dep.t h ----------.----- --- - No. ComCa Capacity' `®� Type��6Ir9- atet+ial s�/V em __ ____ artm _ ____________ Distance to nearest: Well ____________________________________FoundationB �__-`: Prop. Line _________-___:_-_---_ - LEACHING LINE No. of Lines __ --__-_ ---------- Length of each line-----�0 Total Length�- - - -----_--- D' BoxtL_ _ Type.Fifter Material _ ®��_Depth Filter Materia! ---/�_________________________________ i Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _________.______.'...... SEEPAGE PIT [ ] Depth ____________________ Diameter ________:_______ Number ---------------------------- Rock Filled Yes [] No C), Water Table Depth ------------------------------------------------Rock Size -------------------------------- DistanceIto nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------.------------------------_) Septic Tank (Specify Requirements) -------------- - ----------------------------------------------------•--------•-•------------------- Disposal Field (Specify Requirements) _-------------------------------------------------------------- ----------------------------------------- ------------------------- l (Draw existing and required addition on reverse side) f 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: f ,/' i "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." V Signed --- - ------------------------------------------------------------ Owner Title ---F`- �1 G��--�L lw-r, ---------- By '" - (If other th owner) FOR DEPARTMENT USE ONLY � %�� -` ✓ APPLICATION ACCEPTED BY _.._. _--. DATE ----I/71-'__7 ________________ ---- ---- ----- -- - ----------------------------------------------- ------ BUILDING PERMIT ISSUED ---------------------------------------- -------DATE --------------------------------- ADDITIONAL COMMENTS --------- ---------------------------------------------------------------- r -------------------------------4--------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------- -------------------------------------------------- --------------------------------------- _'_! _ _ __ _ _ Final inspection by: ------ := - - - Date `�� -�' -------•.------ SAN JOAQUIN LOCAL HEALTH DISTRICT 4 � � E. H. 9 1-'b8 Rev. 5M.