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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------- ------x:,30 .y r (Complete in Triplicate) Permit'=No. -7j- ____ -_-__----. This Permit Expires ] 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 incompliance with County Ordinance No. 549 and existing Rules and Regulations. �-,�'T JOB ADDRESS/LOCATION .---.. ------ ' _ __ ------_---------------CENSUS TRACT Owner's Name ------- = ----=-- ----- ------ ------Phone -Wy-----7� .. Address ------------------ - .=130 rr__ � ��-- , a6------ - - -- ----- - - �- ------•--� City -- -- Contractor's Name -------- - �-----_S47 x ---------------License # 1(9�P_Pf-------- Phone 9766`?Jo.07...... Installation will serve Residence ❑Apartment House�❑_Commercial :❑Trailer.Court ;❑ Motel ❑Other ----------------------------------------- Number of living units:_._/------- Number of bedrooms3-___Garbag Grinder ___ ____ Lot Size _________________ Water Supply: Public System and name ---------------------------e- ;-- "ii----------------- --------------------------------------------Private ❑ 'y Character of soil to'a" depth of 3 feet: San ❑ Silt❑ Clay 0 Peat❑ Sandy Loam .j Clay Loam ZJ Hardpan ❑ Aclobe'�% Fill Material .----------- If yes, type %_______________________ (Plot plan, showing size of—lot, Yocation of system in relation to,gell-s, 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,J PACKAGE TREATMENT—[_]--SEPTIC TANK [. ] ` Size--------�------,:-------------------------- Liquid Depth -------------------------- Capacity ------------------------- Ca acitY ---- ---- ---- -I---- Type -------------------- Material---------------------- No. Compartments ______.__. _ . ___--- Distance to nearest: Well __----------------------------------FoEundation ---------------------- Prop. Line ___._______m......... LEACHING LINE [ ] No. of Lines --------- _____________ Length of each line__!_____._______'___.______ Total Length _________.___.__--__-----_ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---------------.---..-.. _--- ............ I Distance to nearest:: Well --------�- �-��_�Foundationl `___--------------------- Property Line ---------.._____._...__. SEEPAGE PIT [ ] Depthf,)� ________ Diameter ________________ Number -------------1------------- Rock Filled Yes ❑ No C] Water Table Depth J------------------------------------------------Rock Size ------------------► Distance to nearest-. IPell ________________________________________Fundation ---------------I_____ Prop. Line ....................... 0 REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ f---t-e- -------------------- __________________:______) Septic Tank (Spec fy Requirements) ___._____ _ , , 1� Disposes! Field (Specify Requirements) i ;✓ X- -----.-1 ---- t�-- A' ----g -------------- ------ Y ____________ - _________________________________________________________________________ _ J-1y1 _-------_--------------------------------------------------------------------- _________________________________r--.-.___-._____-______ ________________-__-__________-___________„_____-__-___ ---------- {Draw existing and required addition"on,reverse side) I hereby certify that 1 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 liven- I 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 ---------- ------------ ----------- Ow rT it ` BY --------- f other tha ner) FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY ---- ---- -- --------- - ��p-otlit'd------------------------------------------ DATE 1Jr `1�' 1----------- BUILDINGPERMIT ISSUED ------------------------------------/------------------- ---------------------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS . - - ---_--fir-_ �'_�-----------�------------------------------------ ------------ -----= ---- - -------------------------------------------------------------------- ---------------------- - - Final Inspection b �. - -- -- --- ------------ PY �� ------------------------------------------------------------------ Date = 1� 5AN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M