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FOR OFFICE USE: APPLICATION"MIM-SANITATION PERMIT; ..........--------_-----------•----- Permit Na: ............... (Completo in Tripiicate) This Permit Expires 1 Your From Date Issued Date Issued .•S.J��..7� Application is herebyrn a to a San Joaquin La Healt District for a q permit to construct and install the work herein described. This application is made in compliance with Count Or,rdr�din�a-nc/e No. 549 a xisting Rules a nd Regulations: JOS ADDRESS/LOCATION ... ...........• ._.._..!.. .... .......CENSUS TRACT .......................... Owner's Name Phone=F�� ................................. ... . h `�S`�-�/�-�i� Address .... f11� U � - - ................. CI .................. r ✓f ; . _. . Contractor's Name ,� ~----yr -.._...� .... License # 22rr:�Jj... Phone . -?.......� :. Installation will serve: Residence❑Apartment House❑ Commercial railer Court ] �� Motel ❑Other ----------___............................ Number of living units_____________ Number of bedrooms -------.-...Garbage Grinder ............ Lot Size -.� ................. Wath Supply: Public System-and name .......••.................................. ............-------•----.........................................Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat❑ ndy 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. NEW INSTALLATION: (Nonseptic tank or seepage pitpermittedif public sewer is available within 200 feet,) r f PACKAGE TREATMENT f ] : SEPTIC TANK{ ] ......... Liquid Liquid Depth .5;_�..................... . f Capacity - Material ..._ No, Cmatents - ---••• Type . ,: } Distance.to nearest: Well -_ z!. ............ Prop. Line 5 ..Foundation ._ �.. LEACHING LINE. [q__No. of Lines ---______________-__-jength of each line./d..�'� .... Total Length 'D' Box .l. ........ Type,.filter Material Filter Material ....,/ . ............................. { Distance to nearest: Well•....................... Foundation Property Line ..................1...... SEEPAGE PIT [ ] Depth ..------------------ Diameter ...._........... Number .................... Rock Filled Yes ❑ No ❑ Water Table Depth _............. �.................................Rock Size ......_ ........................ Distance to nearest: Well ................ .___...Foundation ._................... Prop. line ......:...... REPAIR/ADDITION lPrev. Sanitation Permit# ....---------------------.................... Date ............_..................... ) Septic Tank (Specify Requirements) ...---•-----......I..::'�. ........... .. -... --- Disposal Field (Specify Requirements) --=-----=-----•--- -•--• -------------------------- -------- ----- (Draw existing and4equired addition on reverse side) I .hereby certify that 1 have prepared this applicatioWand 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 ttcen- sed.agents signature certifies the following; "I certify that in t6 performance of the work for which this permit Is issued, .I shall not employ any person in such manner kas to co sub- ct to W man's. ompensation laws of California." Signed _ Y" _-- Owner ` ..._. d � -�L' �. SY -------•- ; Title _... l... {If other than nen} FOR;DEPARTMENT USE ONLY ' APPLICAT EPTED BUILDING IOPERM TCISSUEDgY---- �--------•- -C�------- DATE ......DATE �.... .� :. ADDITIONAL COMMENTS ------------- --------------•---- _. -------------_--------- --------... —......_...-----_.Z------- --------- ------------------------ ----- --- -----------------------• ............ ------......................._....... . I ------------------------------ ------- - --- - -- -.--------....-•---------------•-----•---------------------------...--• ----------------- - - Final inspection by: _...._. . .._. (S........ ..... ...........•......:............_...-..... Date .. ��_ iH 13 2t 1-68 Rev. 51 N..JOAQUIN LOCAs HEALTH DISTRICT 8 7!1M 3