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' FOR OFF1C� USE: APPLICATION FOR SANITATION PERMIT _ Permit No: ----------------------- (Complete in Tripiicatel�-'^-J" ] - - --------------- ------------------ - 7hisPermitaExpires--,YearFrom•Datelssued-i- �� Date Issued ------------------- II Application is hereby mlade to the San Joaquin Local Health District for a permit to construct pnd install the work herein described. This applicationis made in compliance with County Ordinance No. 549 and existing Rules and Regulations: !I RD.JOB ADDRESS/LOCATION °'2 , ---, -----Jt✓J I�TCC1--4++ ---------i�-Q.------------------CENSUS TRACT ----�`.?/-.------ ' Owner's Name -------- •. L-- Q -----�------ 17 ICY - -- -- -------------------------------------------------Phone. Address ----2.1.3,3-0 " -- Contractor's Name OWN.5, ---_------'L n e�fi# - _-- t 'f - _ -------------- Phone ---------------- : Installation will serve: Residence ❑Apartment House❑ Commerciall8 rai-w-$ Motel ❑ Other ------------ . Number of living units:--- _---- Number of bedrooms -------Garbage Grinder// LotSi _''G - - Water Supply: Public System and name ----------------------------------------------- E ---------------------------------------------'�'---„�-�=,:_11--------Private Character of soil to a depth of 3 feet: Sand'❑ Silt Clay D Peat❑ Sandy LoamClay Loam II Hardpan ❑ Adobe ❑ Fill Material -�i��--- If es, p Y type= `_,--------------- € (Piot plan, showing size of,ilot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No.septic tank or seep a pit permitted if public sewer is ova ilable-witHin`200,feet,j PACKAGE TREATMENT I� SEPTIC TANK '� ` � [ 7 Size___ g_____-- Liquid Depth --- _ r X-�=^ a Capacity Type 1'�RFt}� Material p1V (2 Compartments - u► ---------------------- VY D' tante to nearest: Well Foundation _ _ ------------ -- -- Line ____ ___ i_4_ LEACHING LINE [ No.Iaf Li es ____._�---- r # Length of each line_'-- - Q---------- Total Length: _ �-_ � I s t 'D' Box _ Type Filter Material Depth Filter Material- —_ - rr ! r. ---- -----_--•---- ------- Distance to nearest: Well _______________________ Foundation ------ --------.-------- Property Line ;1--1 3 SEEPAGE PIT [ ] Depth ____________________ Diameter _______._______. Number _______--_____.____t.______. Reck Filled Yes '❑ No C] Water Table Depth ---------------------------------------------'--Rock Size ------ ----- ------------------ Dist a 11 nce -------Distance to nearest: Well ___________________ --------------------Foundation .---------------'-=-Pr6p.-Line -------------- REPAIR/ADDITION(Prev. Sanitation Permit# ________------------------------------------ Date -------•---------------------= Septic Tank (Specify Requirements) ----------------------------------------- -- ---------- `- --�r- ----------------- Disposal Field (Specify Requirements) -----------445 W___41^1 _____________ ------ - -- - ----------'i------ ------------------ ------------------------------------------------------------------------- (Qraw existing andre ---------------------------------------- ----------- - ------------------------ gquired addition on reverse sidej 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: 1 "I certif hat int p rformance of the work for which this permit is issued, I shall not,employ any person in such manner as to be su ct Workman's Compensation laws of California.” E Signed - Owner i BY ----- ---------------------- t ----------------- ----------1__c_R-- ------ -Title ---- (If other than owner) - r FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- 4 4 -------------- DATE --- --- ----- BUILDING PERMIT ISSUED ----- --------------DATE ------------------------.- -------------------------------------- ---------------=--------------= ADDITIONAL COMMENTS- --- -- ----- --------------- - -----� - ------------------------------------------------- ---- ---------- ----- - - ._� - _ _.--- -------- ----------------- ----------------- ----------------------- ------- ------------- - - - _=W= _,:7 ------- -Al -- :7 - ----------------------------- --------- - -- - ---- - Final Inspection by: ----------- - ----- Date --------------------- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M