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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------ - --- Permit No: (Complete in Tripllicate) ------ – This permit)Expires 11 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District forapermit to construct and install the work herein described. This application is made.in compliance with County Ordinance No.-549 and existing Rules and Regulations: f / JOB ADDRESSjLOCATION -"'r-Il------ --�----�'-"1h-�-�® ts�i `��--� --��----Ar�5.r.T= CENSUS TRACT -----6----- --- KPR_ ----- - ._�� - - Owner's Name ------- -------- ----------- PJ H PR = -_-�-& - _.Phone r Address -------- -----MOM*----� � - �--3" ��---- - - -----------. City _l ilgaT -------------------------------------------- s Contractor's Name ----OWE-I K--- ------------------------------------------ ------------ ---.License # ---------;----"--------- Phone ------------------------------ ; Installation will serve: Residence R<p-artment House❑ Commercial []Trailer Court ❑ Motel ❑ Other -------------------------------------------- Number ------------------------------------- ----Number of living units:----- ----- Number of bedrooms--'-:__;?—___Garba_ge Grinder Wa___ Lot Size __- _______________ Water Supply. Public System and name ---------------------- ----------•----------------------------- ----------------------------------------------Private ]e— Character of soil to a depth of 3 feet: Sand]] Silt o Clay ❑ Peat❑ Sandy Loam e Clay Loam,E] Hardpan ❑ Adobe ❑ Fill Material W 0__1f 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,) \, } n [ x PACKAGE TREATMENT [ ] SEPTIC TANK'[c'�j/ Size------ ___�__`�__.. -- ._ _Liquid Depth ___ _ Capacity _--g_o®__.___ Typ9/3rf�0_B___ Material---CONCr-_- No. Compartments ------- . .... Distance to nearest: Well __.________----_--_____' .Foundation ______-______-10- Prop. Line ________________- V LEACHING LINE [] No. of Lines -___~___4Length of each line--------------- ----_ Total Length �-F------ 'D' Box ._'--- ----- Type Filter Material Q_ __Depth Filter Material ---- �� r� Distance to nearest:-Well -------------5- __ Foundation -------------- ___ Property Line. _-________ _----I...~__ SEEPAGE AIT [ ] Depth ---------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No .0 Water Table Depth ---------------------------------------=--------Rock Size ------ ' Distance to nearest: Well a----------------------------------------Foundation_ -------------------- Prop. Line _--..___--______..__.. • REPAIR/ADDITION(Prev. Sanitation Permit# _.___-F.._-__-____.____-------------------- Date __________ ____________-__________) SepticTank (Specify Requirements)A--------------------------------------------------------:-------------------- ----------------------------------- -------------------- Disposal Field (Specify Requirements) -------------------------- ----------------------------------------------------------------------••--------- i -------- ----- -- = - - - -- - -------- --- # (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 permit is issued, I shall not employ any person in such manner as to become subject to Workman's Pmpensation aws of California." Signed --------------------- Owner I By ----------------------------------------------------------------------------------------------------- Title -------------------------------------------- --------------------------- (If other than owner) FOR DEPARTMENT,USE ONLY i APPLICATION ACCEPTED BYi. `Q -------------------------------------------------------------------------- DATE -- ------------------------------------------------------ DATE ------6-""_f. -6 - BUILDING PERMIT ISSUED ----------------------------- --------------------------------------------- -- --------------DATE --------------------------------- ------ ADDITIONAL COMMENTS ---- ---- ---- ----- ---- --- - - ----------------- ---- --- ------ ------------ -- -- --------------------- ------------------------------------------------------------------------------- ---------- - ---------------- ------ ----- ------- ----------------- - - Inspecti - - -------- /1CJ� Date =-------- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT . J f/ I E. H. 9 1-'68 Rev. 5M -�