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FOR OFFICE USE: 3. 7ZAPPLICATION FOR SANITATION PERMIT ---moo: d .- (Complete in Triplicate) Permit No. ---- ---------------------------------------------------------- __----------------------------------------- This Permit Expires 1 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 cee with County �Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _____ _ /--------E------ ___ _ yt .__._ .x544".-CENSUS TRACT ____________ ----------- Owner's Name ---------------- � -------------------Phone,_17t_-.49af'_�_...... Address - --- --- - -,j��-� 1 �_ - - ---- City -- - - ------------------------ ---------- ---Name ________ __ __ t1' _ -------------License #L_ 0S/I------ Phone Installation will serve: Residence Apartment,House,❑ Commercial.:❑Trailer Court :[j 1 Motel ❑Other ------------------------------------------- Number of living units:----- Number.o-f'b'edrooms __ __Garb e G i .der ------------ Lot Size .....�Q-XC-- _________ Water Supply: Public Syste nam name'-----------` `_--------------'4` _ __-- --------------------------------------------Private E] i s Character of soil to a depth)of 3 feet: Sand'E] Silt E']*'�,�Iay ❑� Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan'❑ Adobe,' i Fill Material ------------ If yes, type ---------------------------- (PI'ot 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 ispvailable within 200 feet,) PACKAGE TREATMENT [ ] SEP Size Size_____---- _ _ tf Liquid Depth ___,rSr_ ______________ ti Capacity/Jrffil __ ___ Type ___ Material_ _ ___ No. Compartments _____2 ............. E Distance-_to,.'nearest: Well ____________________________________Foundation -----L.GZ----------- Prop. Line ___�...:...._.__ t LEACHING LINE No.`of Lines -------/-------------- Length of each line-----40-V----- Total Length ,__/6V___---. -..____ 41""_ � / % 1�er Material _� ' _ _ _ _ D' Box .____._:.___ Type Filt _____Depth Filter Material -----/9__i/____________________________ Distance to nearest: Well ------------------------ Foundation ----- .+------- Property Line ---�---~_-.....-. SEEPAGE PIT ( Depth, L____ $_._____ Diameter -�3-ri- Number}------------/------- -- Rock Filled Yes No { Water Table'Depth -------------------- ------------------- -_----Rock Size -- ----�'--�--��'---- Distance to nearest: Well ________________________________________Foundation _4Q___.______ Prop. Line ___S___--_......... REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------- _________ - Date _____--_________________________} Septic Tank (Specify Requirements) - ----------------------- Disposal Field (Specify Re irements} ._ ` _! 1 l i% t -------- ---- - an ' ------------------------------------------------------ r (Drawe)$fisting d required addition on,reverse side] I hereby certify that I-have..prepared thispa plication 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 thelollowing "I certify that in the performance of the work for which this permit is fisued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." I Signed ---- --------------------------- -- Owner } BY / --- ---------- `--- Title ---- } --- ---------------------------------------------------- (If of er t owner) t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------------=------•-----. DATE .(a----,3 -------� 7l BUILDING PERMIT ISSUED ----------------------------------- --------E------ --------------------------------------------DATE ------------- ----------------- ------••--- ADDITIONALCOMMENTS------------'-- T------ I----------------- ----------------------------------------------------------------------------- s - - - ------------------------- ----------- --------------------------- - --------------------_-------------- -------------- --------------------------------- ',r ! Final Inspection by: Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M