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FOR OFFICE USE: APPLICATION FbR SANITATION PERMIT --- ---------------- t Permit No. ----------- (Complete in Triplicate) ---------------- This Permit Expires ] Year From Date Issued 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 ._Z�_6_-ez-- L .______.____________CENSUS TRACT __._______.__.__..____ fC Owner's Name �!� _.f f^rv�3� i' �b--- ..--- -� -------------------- /-�------- Phone ----------------------------- Address --- /✓.Y__ ,' r��C ------�-- ----------- CitY `"ti-- -"` J --- ------•----- ---•-------------- o / Cont`ractor's Name _._f. - .-_- ---� r1 _�.. ----2�-------------------- # Installation will serve: ResidenceLpir artment House❑ Commercial :[]Trailer Court 1❑ Motel ❑Other ------,--�---1--------------------------------- Number of living units:----- Number of bedrooms __('___Garbage Grinder � ._ Lot Size ,�_, � �_'_______________ Water Supply: Public System and name ------ ------ -----------------------------------------------Private — Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe- i Material/A.-r If yes, type ---------------------------- W (Plot plan, showing size of lot, location� of system in relation to wells, buildings, etc. must be placed on reverse side.) t NEW INSTALLATION: (No septic.tank'or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK°[`] Size-----------------------`------------------------- Liquid Depth ----------------------.... N Capacity -=------------------ Type -------------------- Material--- V----------------- No. . Compartments _................ Distance to nearest Well -----------__________-------------- _ _ _Foundation _______ ___________ Prop. Line ---------------------- LEACHING LINE [ ] No, of Lines ''____________________ .Length of each line ------------------------- Total Length ._____--__ p 'D' Box ___ _.____....i�7ype Filter Material ---------------(_.Depth .Filter Material --------'_ Distance to nearest:.Well ___'__-______________ Foundation ____________________.__ PropertyaLine `.._,-_.___ --.. SEEPAGE PIT [ ] Depth -----_----_j ._--# Diameter ------ ------- Number ---------------------------- Rock Filled Yes [I No,,i❑ Water Table Depth - "'--------.--Rock Size ----------------- -------------- - Distance to nearest: Well -----------`--7—--------------------Foundation ---------------------- Prop. Line----"--------- '___.._. REPAIR/ADDITION(Prev, Sanitation Permitk# _ Date __________________________________) Septic Tank (Specify Requirements) ------------- i 7 Lf y - f Dis osaI Field (Specify Requirements) ___ _ �(.-__�____-_-!_f-____ -- Q __'._ <2 _ `_ �.-G ' .r' = -- ------------------------------------ ---- -------- ------------------ (Draw exisling nand required addition on reverse side) I hereby certify that 1 have prepared"this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rule`s 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 this p re m t is issued, I shall not employ any person in such manner as to become subject to Workman'sCompe ati.on laws of California." rr. Signed - --`---- -------- -` Owner ---------------------- --;-- By ---- ____- ---- - -------' '' ------------------- s Title r te ^------------------------ ,,,[�fff' (If�oth an owner) kk_ I f# f{ OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - ---- -----------------------------•f--------------------- ---- DATE VI-7-121..... ------------------- BUILDING PERMIT ISSUED F_ - ----- -------------------------`- -------------- ----------------------------=--------------DATE ---- ------- 11 i ApQ1710NA1 COMMENTS _ Y = -------------'=--------------------------- i ____-------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- _ _________________________________________________________ ______ _______________________ _______________________________________ _____ ____ ____ ____________________________ Final Inspection by �� - 5 --- --V�------------------------------------t-'------------------------------------------.Date 3_112 -��-------------- i SAN JOAQUIN LOCAL HEALTH DISTRICT- E. H. 9 1-'68 Rev. 5M