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_ FOR'QFF.ICE USE: APPLICATION FOR. SANITATION PERMIT 41 49 �g 7/; -------------- / (Complete in Triplicate) Permit,No. . - I /4 7- ---------- This permit Expires 1 Year From Date Issued Date Issued : _`--7/--..• Application is hereby made to the San Joaq.uin_Local Health,Di.strict for apermit to construct and install the work herein described. This application is made in compliance with County Ordinanc No. 549 nd existing Rules and Regulations: JOB ADDRESS/LOC 10 1 _____ ... _^___*i- -3 ___. 3 a { CENSUS TRACT Owner's Name ---- ��- .�'' -�(��-------------------- ----------- -------- --Phone ------------------------------------ Address f �= -------- ------- "City t._ . License # _ Contractor's Namei 1 -C----F--= -- �"'� ;.- --` "' � Installation will serve: Residence VApartment House❑ Commercial :❑Trailer Court i❑ �. Motel ❑Other --------------------------------------- Number ----------------------------- -Number of living units:'F --- N 6 tuber of bedrooms __2-----Gar 2_____Gar a e rind "._ Lot Size _ ,- __ Q �. ' ~f ._ Water Supply. Public System and name ---_-•--------_ i-- -_-- _-- f ---- - -- --- ------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'El Peat❑ Sandy Loam ❑ Clay Loam ❑ ' a I Hardpan ❑ Adobe Fill Material rV e�If yes, type _________-______________ r (Plot plan, showing sizelof lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic lank or seepage pit permitted if public sewer is available within 200 feet,} . t� tf PACKAGE TREATMENT { ] SEPTIC TANK! ---y ._. _ _ Liquid Depth _��Z---- Capacity _�y_ --�-___.___ Type �__��E.. c':�_ "Material hNo. Compartments _c_ �...__ . Distance to finer est: Well ____'`�__ _____________________Foundation _.— ----___.__Ll � Prop. Line ------_______ LEACHING LINE No. of Lines - ----------_ Length of eafch line._. .5_ °d"_ -S__:__ Total Length __ ___ __--- D' Box -_ __ Type Filter Material f'lx_�_�_ ----_.Depth Filter Material _-__��____!__.__._____-_________________ 4 Distance o nearest. Well ____� ______ Foundation _._. -------- Property Line ------___________________ SEEPAGE PIT Depth '________ ___ _____ Diameter _ _____ Number ___r --------------- Rock Filled Yes No-I❑• Water. Table Depth _._.__..__._Rock Size .______ istance to nearest: Well ----------------------------------------Foundations____.___-------- Prop. Line - -•----•-----_ -- REPAIR/ADDITION(Prev. Sanitation Permit# -------.--- — - ---__ -' _�„-1 ---s Date ---------------------------------) { SepticTank (Specify Requirements) ------- ---------------------------------------------------------------------------------------------------__----------------------------- Disposal Field (Specify Requirements) _=__________ -- - -------------------------- 1 i ------------------------------------------------`_ ---- - ------------------------------ -- -- - ----- ------------ ------------------------------------------- --- ------------------------------------------------------------ --------------------------------- ------------------------------------------------------------------------------------------------------------ .(Draw dxisting 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 aind 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.” i Signed --------------------------------------------------- Owner , i BY ------------ ------ = ----------------- Title --- �� �-- - 1 -`----------------- (If the tan owne6 ' F R DEPARTMENT USE ONLY ACCEPTED BY 4 -i DATE --------- APPLICATION BUILDING PERMIT ISSUED -- `. "r �'-----"w` _. - D T -------- ADDITIONAL COMMENTS _.Ja 9 7J------ ------------,a. _ .f-e�'H_c� _ .d/ "�1------------- -- ------------------------------------------------------------------------------- -------------------------------------------------------------- --------------------------------------------------•---- ------- ------------------------------------------- ----------------------------------------------------------------- ---- ---- ------- -------- - - -- - ---- _ -------------- FinalInspection by ----------------- ____--- --------------------.---------------------------------- -------- --- - --------.pate ----- fi SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M "', % ik