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4 ..� y FOR.OFFICE USE: APPLICATION FOR SANITATION PERMIT G ------- --------------------------------------- ' (Complete in Triplicate) Permit No. --y_Z__ _ - --------------- 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 with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . -/.. ------------ 104)------ R-Q-----------------------------CENSUS TRACT ----------------------- Owner's Name ----t,,c._D k �-�_ci_i 4_,06------------------------------------------ -------------------Phone _?J 23_ U y -- Address2-17 y-f----------- ---------- -----------------------" City 11;1-AillT C A----------------------------------- - Contractor's Name - ---A--4 ..-- f/ .� License # � JR- Phone _ ��T' ! Installation will serve: Residence [<partment House❑ Commercial :❑Trailer Court ;❑ .Motel ❑ Other -------------------------------------------- > / Number`of living units:---,/----- Number of bedrooms __,3___.Garbage Grinder --__-- Lot Size _l:1O_____ _____________ 1 . Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private ®� Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy.Loam [Q'�Clay,Loam ❑ I r _ Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type ---------------------------- (Plot ________________________ _(Plot plan, showing size of lot, location of system in ation to wells, buildings, etc, must be placed on reverse side.) seepa pit permitted if public sewer is available within 200 feet,) NEW INSTALLATION: (No septic tank or PACKAGE TREATMENT I ] SEPTIC TANKSize___ ---- Liquid Depth ____6------------------ Ca city .� ------- Type -------------------- Material----------- No./Compartments ---- ........ i istance to nearest: Wel! ----5-Q------------------------Foundation ---/0------------- Prop. Line -----%T LEACHING LINE No, of Lines -----A-------------- Length of each line ----� _____-_____ Total Length � D' Box .__ ------- Type Filter Material Depth Filter Material ____/$?-------------------------- Distance to nearest: Well ---1-5'P------------ Foundation _11f--------------- Property Line ___45 ._-__.:.__- SEEPAGE PIT [ ] Depth _____ _____________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ y WaterTable Depth ----------------------------------- ------------Rock Size -------------------------------- Distance to nearest: Well _,____________________________________Foundation --------------------- Prop. Line ________________-___-- REPAIRJADDITION(Prev. Sonitation!Permit# -------------------------------------------- Date ------------------------------=---) 1 Septic Tank (Specify Requirements) - --------- ------------------------------------------ _----------------------------- --- ------------------- Disposal Field (Specify Require°ments) ---------------------------•--------------------------------------------------------------------------------------------------------- i Fi ___-"_______-__-.._______"__-"___________________"_ _ ___________________------------__-__________-_______--___-_______________________________-------------______________-___________-__---__- (Draw existing and required addition on reverse side) i 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 become s bject to Work an's Compensation laws of California." Signed ---- - ----- ��------------ --------------------------- Owner By ------------ -- - ------------------------ -------------------------------------------------- Title ----------- ---------------- ------------------ (If other than owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ____,1___-._ � .� ;9�--"- c ---------------�-- DATE - _5'.-:-J-77----�---�-^. BUILDINGPERMIT ISSUED ----------------- ------------------------------------------------------------------------L--------------DATE ..- ---------------------------------- i ADDITIONAL COMMENTS _"__ ------------ ------------------------------------------------------------------ ---- -- -------------- ----------------- ------- ------=-------------------- - ------- ---- --- --------------------------------------------------------- - -------------- - ---------- ------ ----- Final inspec gates--- --- ------------ fi ----------------------- ------ _ SAN JOAQUI LOCAL- HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M