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FOR OFFICE USE: ^-3 J APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. --------------------------- ------------------------ 4t!. aDate Issued __5----S-� --------------------------------------------------------- This Permit Expires 1 Year From 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/LOCA ION ._ [�- -- ---,--- k ------ t --------------------CENSUS TRACT ---------------------_- VAZOwner's Name Aft--------- - W-f-W—----------------------------------•--------------------------------------------.Phone �e-7�. ------_--- Address ....... � _Gl t`Il G= ------------------ City ,feg�pa ---------- Contractor's --------License # ------------------------ Phone _4rer'''-wa_,Ip' Installation will serve: Residence Apartment House[] Commercial ❑Trailer Court if] Motel ❑ Other -------------------------------------------- Number of living units:------ --._ Number of bedrooms --a-----Garbage Grinder ____.--- Lot Size --_-----_-_ --_---_-_- Water Supply: Public System and name ------- -------------------------•--- -------------------------------------------------------------------------Private Character of soi l to a depth of 3 feet. Sand'EJ Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam 0 Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ______-------__-----_-__- (Pl'ot 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,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size--------------------------------- - ------------ Liquid Depth -------------------------- Capacity ------------------- Type -------------------- Material------------------- -- No. Compartments ---------------------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ..... ................ LEACHING LINE [ ] No. of Lines Q1v-t----------- Length of each line---_-_'4�0' Total Length ------�4--�.__--._-__-- 'D' Box ---)C----- Type Filter Material -__-i&C.k----Depth Filter Material ----IAr------------------------------ Distance to nearest: Well --------------- Foundation -----Ad_1--_--_-.-- Property Line _-477 _--_....._-- SEEPAGE PIT [ ] Depth ___asT--------- Diameter X---_----- Number --------sf------------------ Rock Filled Yes No Water Table Depth -----?------------------------------- -------Rock Size -A ; .0 Distance to nearest: Well ------/Q0------------------------Foundation --- - !� �Q - ----- Prop. Line -•- ------------------ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------.------------------------) SepticTank (Specify Requirements) -------- --- ------------------------------------------------I------------------------------------------------..---------------------------- DisposalField (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- ---------------------------------- ------------------------------------------------------- --------------------------- fDraw 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 Son Joaquin Local Health District. Nome 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 Compensation laws of California." Signed ------------- --- ------------ --------- ---------------------- Owner BY - --------- Title ------------- :---- (If other a owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -------"------------------------------------------------------ DATE c BUILDINGPERMIT ISSUED -------------------------------------------=-------------------------------- ---------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS Inspection b - ---------------------------------------------- --- - --- ------------ --------- - Final Y- -- - - ----- - -`-----t------- - ---------------- ----------------------••---------------------------------------.D -at-- e -- :--- --�'-- -- - ---- � ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.