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OFFICE USE: FR / APPLICATION FOR SANITATION PF IIT ]� �/6 I f tw-x /3L�P r Permit No- --------------------- (Complete in Triplicate) ------------- ---------- ------- ------------------------------------- __________________ This Permit Expires 1 Year From Date Issued Date Issued 0-12 ...... �- 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 c,g Iianpte weth Co_rlynty Ord-e No. 549 and existing Rules and Regulations: JOB ADDRESS/ CATION - / a'f`C� U1_ -'"-� U� CENSUS TRACT . Owner's Name )--�--------- °?_.1-ry _ ---------------------------------- ---------------- ------------Phone-------------------•---.---•- • - -- Address ------------------------ ----�-�-`��=-�------ -------------------- City -----------------------------_ ---------------------...----------- ' � -------.License #a X71_�9 _ Phone Contractor's Name r -- ------- Installation will serve: Residence partment House Commercial 0Trailer Court ❑ is { ( , Motel ❑ Other -----------------------------•----- ------- Number of living units_____________ Number of bedrooms r�------Garbage Grind Lot Lot Size Water Supply: Public System and name ---------------------- -------- --------------------------- Private " Character of soil to a depth of 3 feet: Sand�❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan (] Adobe P Fill Material _-!L __ 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![ Size________XX',. ....)C�_ ____ Liquid .Depth _____�f4__.......... Capacity ___�.l- �______ Type ° t_�-_ Material Ly s_d�,.r_�.t_ No. Compartments .................:.... d Distance to nearest: Well ------S .. ...................Foundation ----------- Prop. Line ___. ------ LEACHING LINE No. of Lines -- ------- ------- Length ofeach line--f,--, - -__ -,�._.____ Total Length .. --_ •- ---------- 'D' Box _ _ Type Filter Material QCmer--u epth" Filter Material ___ __ _-______________________•.._... Distance t nearest: Well _____s'" _!_______ Foundation C ____-----------.- Property Line ___. SEEPAGE PIT [ Depth ___ ______ Diameter _ _____ Number ---- ______________ Rock Filled Yes No Water Table Depth --------C d-/-------------- ----•-------Rock Size r---------- f e Distance to nearest: Well ____.__/43-0 ....... _r_ -r_______ Prop. Line ..�� ---------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------.) SepticTank (Specify Requirements) -------- ------------------------------------------------------------------- ------------------------------------------- ------------------- �- Disposal Field (Specify Requirements) ------------ ----------------------------------------------------------------------------------- ti -----------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, I shall-not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----------- - -- -------------------------------------------ff--�-- -------------------------- ..tiOIner ^ ------------------ - , (If other tha ow er) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- - - --------- ---- -�1¢�--------------------- DATE -_.. -�----------- �. . BUILDING PERMIT ISSUED _ DATE F ADDITIONAL COMMENTS .-_G —XI- z----_4� �rra _-� _ s v� _ _ �i--�� -- a ----------- ----------------- -------------------------------------•---- 1 --- '--- - ----- -------- -- ---------------------------------- ---------------------------------- -------------- ,. ----------------------------- ---- - Final Inspection by: Date �'�'' oZ-- _ s ----- ------------------------------------- ---------------•----------- ------------•------- ['" SAN JOAQUIN LOCAL HEALTH DISTRICT f E. H. 9 1-'68 Rev. 5M G