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... -FOR OFFICE USE: r . ^ � APPLICATION FOR SANITATION PERMIT _: //� -- ----------------------------- f Permit No. / X_g M €.._ - ------- ---------------------------------- - / --------------------_------------------------------------ This Permit Expires 1 Year From Date Issued Dote Issued _�C-�_�� F - 7 ;. 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 .__L- __._ �___.--�_�__,___ _--_ - -- ----------A-1>5----------CENSUS TRACT Owner's Name Af211i ZZ-------G_UAl_1i'trVle_m------------ ----- -------------------Phone g �� .-------- Address39k----- Coro Ie- .---- --=------------------------------------------------- City _—".-IV ----------------------- ;'----------------•----- Contractor's Name ---- _________C=a/_tel/,-p____- License �� _ /0__ Phone t��- - � - -- Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- j Number of living units:____j____ Number ofbedrooms _..----..Garbage Grinder ________- Lot Size Water Supply: Public System and name ---------------------- ------------------------------------------------ -•---------- -------------------------Private Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat Sandy Loam ❑ Clay- Hardpan lay 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 seepa pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Size_ , _)e ------------- Liquid Depth ._________,_.._. Capacity a__,__ Type Material__ _4 _ No. Compartments __�________________ istance to nearest: Well -------"f------------------Foundation __________ Prop. Line __ 4�.....______ Q LEACHING LINE No. of Lines -----*Y-------------- Length of each line------ _ ---------_-_-- Total Length .___C�_____._____..- 'D' Box _�—,�?_ Type Filter Material-P._Oe --------Depth Filter Material __«_J___________________________________ P Distance to nearest: Well _____. _r________ +oundation ... _e_r________._ Property Line __ �______________ i �� Depth ------f1:----------- Diameter �__X__t�- Number"_ __.__.______ _; rRock Filled Yes No i❑ Water Table Depth ----- ----------------------------------Rock Size Distance to nearest: Well ----------------------------------------Foundati ..._......._-- .___ rop. Line --------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------------------__--) SepticTank (Specify Requirements) -------- -------------------------------------------------------------------------------------------------- --••-----------------•---------- DisposalField (Specify Requirements) -------------------------- •-----------------------------------------------------------------------------------------•---------- ,-- --------------------------------------------- -------------------------------------- ------------- ----------------------------------------------------------------------------------- (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 "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." Signed --- --------- -- ------------------- ,-y-------------------- Owner ' w Title _._ By ------- ---.------ ------ ----- -- -- ------------------------------------- -------------------------- --- -- ------------------- (If other than owner) FOR DEPARTMENT USE ONLY {� APPLICATION ACCEPTED BY�1 C�'��`------------------------------------------------- --- --------------------------- DATE ---- - BUILDING PERMIT ISSUED ---------------- -------------- ------------------------------- - - ------------.DATE ------------------------------------- ------------------- -- ADDITIONAL COMMENTS ------------- - ----------------- -- ------------------------------------------------------ - ---------- { ----------------------------------------- ----- -------------------- - --- J -- ------ 1 ------------- ------ --------- -- ---- --- ----------------------------------------- --- Final Inspe ----------------------------Date � - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M., f r