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FOR OFFICE USE: �` APPLICATION FOR SANITATI`_"'l PERMIT ----- -------- ------------------------------ ---------- � � � �- Permit No. __��© This Permit alth DiExpires ] Year From Date Issued x (Complete in Triplicate) ------------------ --------------------------------- -- Date Issued _ ------------------------------------------------------ - Application is hereby made to the San Joaquin Local Hestrict fora 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 ----------------------------------------------------CENSUS TRACT --------------•----------- Owner's Name f!_C - ,41X1_fC----Pf�l'1`-/� - ----------------=- -------------------Phone Address --.43,_& -'i je�----------•-------------------------------- ------------------------------------- City ---3 o.0 C_-1 0-M----------- -------- Contractor's Name --lkE5 - -Pr1_C_tiS- /�- -d-Cr-IR----------- --------License # _l 7 8. ---- Phone Installation will serve: Residence ❑Apartment House�❑ Commercial :❑Trailer Court 1 . Motel ❑Other -------------------------------------------- 3 Number of living units:_--- -- Number of bedrooms --- ----Garbage-Grinder _____..___9 Lot Size ______ _____________________________________ Water Supply: Public System and name --------------•-------�--------------------------*------ ' Private El Character of soil to a depth of 3 feet: Sand'❑ Silt❑ $ Clay ❑ IPeat ❑ Sandy Loam ❑ Clay Loam .D Hardpan ❑ Adobe 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.) MQ NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] \ . PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size----------------------------------- ------ Liquid Depth ---------------------.----- V Capacity ---------------- -- Type -------------------- Material---------------------- .No. Compartments ------ ------- Distance to nearest: Well ------------------------------------Foundation -------------------- Prop. Line ---------------------- LEACHING _-_------ :_-----LEACHING LINE [ ] No. of Lines ____.____ ----- -_____ Length of each line---------------------------- Total Length _____________ - --------------- 'D' Box ------ __ Type'Filter Material --------------------Depth Filter Material -------------------------------_____________ k Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ________-________---_ SEEPAGE PIT [ ] Depth ------_-------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No .0 Water Table Depth -------------------------- ----------Rock Size ---------------------------- Distance to nearest: Well ------------------------ ---------Foundation .------------------- Prop. Line --------------------_ REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date ---_-----------------------_------) SepticTank (Specify Requirements) -------------- ----------------------------------------------------------------------------.-- --------------------------------------------- Disposal Field (Specify Requirements) _259,T....17`.4�___4/-YC-----t--- ------fl_-_10 ------ ------------ ------------------------------ ------------------ ------------------------------------------------------------- ----------------------------------------------- i -----------__________________________________________ _ _ _________-__.__________ _ _ __ _-______.__-__________--_____-________-____________-___-__---____-__________________.____-______________ (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, 1 shall not employ any person. in such manner as to becom subi t to rkman's Compensation laws of California." i Signed _ ----------------------------- Owner By ------------------------------------------------------------------------------------------------------- -Title ---------------- (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------- - 4 VC----------------------------------------------------- DATE ---6-/1,5165------------------ BUILDINQ -/1,5 -69------------------ BUILDINC PERMIT ISSUED -------------------------------- ------------------------------------ ---- -----DATE _.---------------- ---------------------- -- - --------- ADDITIONAL COMMENTS --------- ------------------------------------------------- ------- ------------------ -------- ------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - -- / ------------- - ------------------------------------------------------------------ -- ------------------------------------ ------------ ----------- Final Inspection by --` = - - ie%P- -- - ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 2 E. H. 9 1-'68 Rev. 5M. i