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4. + FQR OFFICE USE: APPLICATION FOR SANITATION PERMIT . (Complete in Triplicate) Permit No. .7� ........... ................... �...... This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is m de in compliance with County Ordinance N9. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATIONWO—till.� ......CENSUS TRACT .-•....................... Owner's Name I' £ � .._ �f�f?1�.... L4'� ..-R� �I ................•..........------ .............----•-..Phonen.................................. Address�-/Ypv N.-- .►':+rLeekLr1 . < <� ..��.Uret.4�.t�1...�' t.... City ...... .............•...-•----..,..----............. ,� 6E . Contractor's Name .�4.�....��I_t:r�,cs�..d.��y__...s�...i?�',..................License #�..�_�'��I�.�_ Phone .....�.. ........... Installation will serve: Residence ❑Apartment House❑ Commercial ❑Troller Court 0 Motel ❑Other Number of living units:............ Number of bedrooms ............Garbage Grinder ------------ 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❑ Fill Material ------------ If yes, type ............................ (Plot plan, showing size of lot, location of system in relation. to wells, buildings, etc. must be placed on reverse side. Y NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer ris available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ize. .1;r ------------------- Liquid Depth ......... Capacity _.. p Y -- Type __ --•- •- •-. fierial No. Compartments -., - N Distance to nearest- Well __ ...... . . -. .._._ Prop. Line _... ,._ . r . ............... .............Foundation ....._...��..--• p '�•--------- LEACHING LINE No. of Lines ....._ ---------------. Length of each ine..___f� ,....._... Total Length ....t- `....... D' Bax .._. ..._ Type Filter Material - Depth Filter Material ......161'; .��........................... Distance to nearest: Well /�� •i�'._••--•-..--- Foundation ..... ....... .......... Property Line .- SEEPAGE PIT r I 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 sidel 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, l shall not employ any person In such manner assup" .. to be a su t to Work an' mpen tion Laws of California." 4' Signed .......L.. . ..._. .... . By •......................................... (if other than owner) .. . Title .... ._ FOR DEP TMENT USE O Y APPLICATION ACCEPTED BY .......... ......................................................... DATE _..7- ...... BUILDINGPERMIT ISSUED .......................................... .................................................-................DATE ....................................,...... ADDITIONAL COMMENTS .......................................I................. ._..... .......................... .•....---.........-•------....... ........................................................... ......... .................................................... .. . Final Inspection by. ------ - ------- - ......... Date ..�a.y3.1..=,� ................... .......... ••-•••......-- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 24 1.'68 Rev. 5M I2� a y/ /1tO�C� , /J��f/t G �-_ 7172 3 X