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FOR OFFICE USE: ` 6 V 3 w APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) 7C?. ________________________-_.____.______________._""___"- 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 __�CXO__-kAo�"p'�" 57vw CENSUS TRACT .._____-__ ----)---------------------------------------------------- Owner's Name ---------------------------------------------- -------------------Phone _q� 16-1---------------- " ` / Address . '1 k-\-----E -_W1 -'� \ City --- �� --------------•------------------------------------------- Contractor's Name ----- Q-1---•------------------------------------------------------------------License # -------- --------------- Phone ------------------------------ Installation will serve: Residencex Apartment House❑ Commercial ❑Trailer Court f] Motel ❑Other ----- ---------------•-- ------------------- Number of living units. ------- Number of bedrooms -_ _.__,Garbage Grinder Na___ Lot Size _-_1_ �_ _ ___._____-- t __- Water Supply: Public System and name ___ Cal, ____________________________________________Private El Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe.X dobe.X Fill Material _� QQJf 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,) O PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -__----------------------- v Capacity ��.--_--- Type ___ MaterialNo. Compartments __c _______________ Distance to nearest: Well __of f�_______________________Foundation _10------------ Prop. Line ___----t------- LEACHING LINE [ ] No. of Lines ---a- --------------- Length of each line------250_'FeZ�___ Total Length 'D' Box -_-�- Type Filter Material S .'C ___DepthFilter Material -___I�__rPC'Ke_&__________________ Distance to nearest: Well _.tjh:� )j__________ Foundation l5-- ---- Property Line --_�._T�= .__ SEEPAGE PIT [ ] Depth ----- -------------- Diameter _ Number _ Rock Filled Yes ❑ No Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ______________________________________Foundation -------------------- Prop. Line ___-____--___ ....... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________) SepticTank (Specify Requirements) ------------------- -------------------------------------------------------------•----___---------------------------------------------------- DisposalField (Specify Requirements) -----------•- ------------------------------------------------ --------------------------------------------•--------------- ------------------------ ------------------------------------------------ - - --------------------------- -- ------- ---------------------------------------------------------------------------------------------- (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 W mans Compegsation law/*f alifornio." Signed � . . . -- --- --- d-------- Owner By ----- Title ---------------- (If other than owner) ti FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . -- - ---------------------------------------- ------------------------- ------ DATE -- -` - BUILDINGPERMIT ISSUED ---- -------------------------------------------------- -------------------------------------------DATE ----------------------------- 1� N-------------- - --- - ---- --- ------- o --- -- -- -------- --------------•--------- ------ ADDITIONAL COMMENTS ------- ------------------------------------------------ -------------- - ------ ------- Final Inspection b . __ pate _ ------ JOAQVfN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M