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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / - - (Complete in Triplicate) Permit No. --------------------------------------------------------- This Permit Expires 1 Year From bate 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: � r i JOB ADDRESS/LOCATION 'D7------,5_ 6W----{0q1_ ---- ----- ----CENSUS TRACT ------- --•----------- Owner's Name .........ul-0A-`t ------I- IDN'-!�� --------------------------- ------------------- ------------w--------------------Phone -- ---- -------- ------------------ Address --_2.71M=` _t—------ -------------------------------------- Cit F `P�a�1 -------------------------------------------- 1-1Contractor's Name _ - �-._ 1 _--_ -�7- 5_.__.___.___._.License #x .02.3.5Phone Installation will serve: Residence [�partment,House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other ----- ------ ------------------------------- Number of living units: --------- Number of bedrooms _______Garbage Grinder ._k1___ Lot Size ____��___�G____________________ � Water Supply:.Public System and name ---------________ _____._________-Private ---------------------------------------- Character of soil to a depth of 3 feet: Sand' Silt[__1 Clay E] Peat EJ Sandy Loam F] Clay Loam,[] # .Hardpan ❑ Adobe ❑ Fill Material _----_---- If es,t = iY Ype ---------------------------- i (Plot plan, showing size of lot, location of.,system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: _f.(No septicjankor seepage pit permitted if public sewer is available within 200 feet,) PACKAGE-TREATMENT [•.� SEPTIC TANK � , �� j [W" � Size----�/` MI6---------- ---------- Liquid Depth _,e � ---------------- Capacity 1 -------- Type -------------------- Material<"t_«'WlC.- No. Compartments _ Distance to nearest: Well _______S_�_______________________Foundation _._» _______ Prop. Line -----6__.__._________ q LEACHING LINE QJ_ No. of Lines ------ ,7------------- Length of each line--___-]S:__------------- Total Length ,_._ _______..__.. t 'D' Box ___I: Type Filter Materials;_-- ____Depth Filter Material .___ --,----------------------------------- Distance ___.______ �'. Distance to nearest: Well ____47P_______:______ oundation -----/ -------------__ Property Line ------------- SEEPAGE _-_________SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ---------------------------------- ------------Rock Size Distance to.nearest: Well'______________________ _____Foundation - ------------------ Prop. Line -________-_"_....._ REPAIR/ADDITION(Prev, Sanitation Permit# ------------------------------- --------- Date ---------------------------------- Septic --------------------------------_Se tic Tank (Specify Requirements) + Disposal Field (Specify Requirements) ---- a.` _.____RC-7-ri-w.6�tr.6--- R "lrt Q ----------- ----------- ------------------------------- --- � 1 r------- -•------------------------ ----------------- ----------------- - - ------------------- ----------------------------- ---------------- ---------------------------- (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 Son 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 permit is issued, I shall not employ any person in such manner as to become subject to Workman's'C mpensatLon laws of California." Signed -------------------- - � Owner ------------ --- - ---- -------------- -------- ----------------- BY ----- ------------------ --------------- ------- -------- ---- Title ---X (If other than owne FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ____ � �j__C _.____._ E' --------------------------------- ------------------------------- DATE BUILDING PERMIT'ISSUED ---- ------ E ----------- ------------------ --------------DATE - -- -------- -:------- ---------------- --------- E ADDITIONAL COMMENTS _------- --------------_---------------------------- ---------- --------------- --------------- ------------- ------------------------------------------------------------------------------- ------------------------------------ - ------- ---------- j --- - - -- ----------------- -------------------- --------- --- --------------------- -------- - -------------------- - ----- ---- - --------------=- -------------- :------------------------------------- __ ------ --- ------- ---- --- - -- - ---- - ---------=tom-------f Final Inspettioi�b � -- -------------------- Date ---------------- - ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M