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a FOROFFICEUSE: APPLICATION FOR SANITATION PERMIT -------------------------------------------- --- Permit No. _7 7�=1 7-._ __.. (Complete in Triplicate) --------------- --- ------------------------------------ Date Issued --------------------------------------------------------- This Permit Expires 1 Year From 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 . - 6-0�.�..-- --- --"`'v--------��--` (-"--'��-�`"-�--�`-�`-�[----- CENSUS TRACT -------------------------- 19 ---- -------•---•-•----- Owner's Name ---------------i�l�C- --------�-----------• - - hone _ .r �'j Address ----------------------- L �Y" ----� --- ----------- --------- . City --- Contractor's Name a - ----------- ----------License # -1� ©2�<<.._ Phone W6-960 Installation will serve: Residence�<Apartment House-0 Commercial ❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- �j y Number of living units:-----t____ Number of bedrooms ____3----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 Liam •❑ Clay Loam ❑ Hardpan ❑ Adobe* dobe 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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK, S. e___-___�___- - isp --- �--�{---- ----------- Liquid Depth ._ ----- -----------._.. 40 Ty_pe+ Mafieriai__ G__' No. Compartments ------ -- � ----------- Capacity/ Distance to nearest: Well y________________________________Foundation 49 --------- ---___- Prop. Line ___ � ••.•.- LEACHING LINE [ ] No. of Lines f --)C_ Q___ Length of each line-------------------- -- ____ Total Length ----_�`_______------------- 'D' Box -------- -- Type Filter Material 0 ____Depth Filter Material ---------Ae---__________________ _. Distance to nearest: Well _______________________ Foundation __!Q__"f------- Property Line __577.�------.. SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number --------------------------.- Rock Filled Yes ❑ No ❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- ,' Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ____.___.--____-_-__ REPAIR/ADDITION(Prev. Sanitation Permit# _____________________________________---.-- Date ----------------------------------) Septic Tank (Specify Requirements) -------------------------------------------- -x----------------------- ---------------------------------- 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 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 ----------- ------�t� ------------- ------ Owner D BY Title ----------- --- _��.-------- (If otowner) FORDEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- - 1,Wf--------- -- -- - - ------------------------------------------------------ DATE --- Z -'�---------- BUILDING PERMIT ISSUED -------------------- --------- -------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- --------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------ ----------- ------------------------------- -------------------------------------- ' ---- ~r- ----------------- Final Inspection by e'r'r" t" ------------------------------------------ Date - �� ---j----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT (% E. H. 9 1268 Rev. 5M