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Y H FOR OFFICE USE: ' APPLICATION-FOR SANITATION PERMIT 7/ ------------------------------------------ -� (Complete in Triplicate) Permit No ______________________ -------------- � �� Date Issued `_f --- -------- This Permit Expires 1 Year From Date Issued is Application is hereby made to the Son Joaquin Local Health Districtwfor_a permit-to_construct and install the work herein described. This application;is made in compliance with County Ordinance No.1 549 and existing Rules and Regulations: I JOB ADDRESS/LOCATION�L___ _/.__. _____, .'_____ --- --- - --- ---- CENSUS TRACT ------------- ._. k __ ._ ________ Owner's Namew - -� -- �I / 6 Q,// ----- =---=�-�r--�-�---�-f--------------• �- -- -----------------=------------- -----._Phone �_,----- ------------------------ Address ± C3.1_�- k --------- = 1• - �' city ff````// r Contractor's Name�_ _ l' -+*- �'�'r ----License # - ODD ''C- --- Phone .x��7-N1----—7 F Installation Will serve: Residence Apartment House❑ Commercial : Trailer Court ;❑ Motel ❑ Other ----------------------------------• -------- Number of living units..___Ii-I___ Number of,bedrooms ___,01" O.Garba_ge Grinder ___.__ __ Lot Size _._77-- ----------------------------- Water 1 eo ----------------- try w ____Private F Water Supply Public System and name----------------------------------------------------------- - ---------------- ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ a Peat;❑ Sandy. Loom •❑ Clay Loam;❑ Hardpan ❑ Adobe Z Fill Material ------------ If yes type.-.---_- --------- (Plot plan, showing size of lot, location of system in relation:to wells;�buiEd gs;°:etc'must be placed on reverse side.) NEW INSTALLATION: (No septi tank or seepage pit permitted fi public-sewer is a ailable'within 200 feet,) v PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size---------------------------------- -- liquid Depth ---------------------.----. Capacity ----------- -- is Material No. Compartments Distance ito nearest: Well ------------------i------------------Foundation ---------------------- Prop. Line -------•-------------- k li } t LEACHING LINE [ ] No. of Lines ________ Length of each line-'- --I ----------- Total Length ----------------------------- 'D1 Box -1--------- Type Filter Material _ _________________Depth Filter Material ---_=_____-__ _ _.---------------------- IN ___ ____-------------Distanceo nearest: Well ___________________j___ Founda --_____ ___._i___.____ Prope[tya.11ine ------------____________ SEEPAGE PIT _ Depth ,.__----_— -�Diameter-•_---�-___________ Number _____________ i. Rock Filled Yes ❑ No C] I, fi Water Table Depth ------------------------------------------------Rock Size -------`'- --------------- r Distance to nearest: Well ----------------------------------------Foundation -------------- ---- Prop. Line ---------------- . li _ REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------ ---------- D to ________ _ ) 9 Septic Tank (Specify Requirements) ,, 3-_____ _--- -- -- " ------------ -- -- - - r Disposal Field (Specify'I'Requirements) ---,��_-_.-/�_�---- -- ----0--33.1.xZ- ----- ------------- I; ► ``. li -- -------------------------------------------------------------------------------- " (Draw existing and required addition on reverse side) 1 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 permitfisnissued, 1 shall not employ any person in such manner ,- as to became subject to Workman's Compensati.on`lows~of Californip:'r-4- � ._ Signed --- ---- -------------- -� --- -- ------------------------------------ Owner r Title .--- ------------------------------------------------------ BY -------- ------ -- ---- (If other n owner) Ij FOR DEPARTMENT USE ONLY APPLICATION ACC T D i13Y ------W_Z__0J_V°tC------------------------------- -------------------------------------- DATE JIM?/--------------------------- BUILDING _fI --- ?/-------•------------------- BUILDINGPERMIT ISSUED ---------------------------------------------------•-------------------------------------- --------------DATE ----- ------------------------------------- ADDITIONAL COMMENTS!-------------------------------- - �1__ _ ----- . ----------------------------------------------- ------- - --- ------------------- --- ----------------------------- - --- - = ----------- _____ ------- - ---- /- Final Inspection by: -------------- -- - -- - ----- -- -- ------------------- --- ------------------------Date =/•( l - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M"