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FOR OFFICE USE: -- - &PPLICATION FOR SANITATION P16IT ff '------------- (Complete in Triplicate) Permit No. --------------------------------------------------------- his 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 .._ L K _ _____-_ _ -- _ _ -___ SL_lot t4� � ------------------------------ ----------. -----------CENSUS TRACT -------------------------- Owner's Na//me �-l-�'1.-�- im -- C-0VMM------------------------------- -------------------Phone.-�65---!' 4-� ----- Address _V 1-1A----------- --------- ---------------- City -----5 (_,__1&T0__0----------------------------------------- Contractor's _ 1CT2-0----------------------------------------- Contractor's Name --------------------- ---------------------------------------------------------------.License # ------- ---------------- Phone ------------------------------ Installation will serve: Residence Apartment House❑ Commercial)erailer Court ;❑ Motel ❑Other ------------------------------------------_ Number ------------- ---------------------------- Number of living units:__-------- Number of bedrooms �_�_ __-__-Garbage Grinder _N0--- Lot Size ----------- - ---�- - ---------------- Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand)--- SiltX Clay r-1Peat E] 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.) NEW INSTALLATION: (No septic tank or seepage it permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK? . Size------ ____________ Liquid'Depth ..._______._.___._____.__. Capacity (-20Q RType -------------------- Material No. Compartments e�....._..______ Distance to ne r W II SLK_ _____________ _____Foundation .__'__ Prop. Line ----------�`___..__._ 3 Q I Len LEACHING LINE No. of Lines ----_ Length of each line------ Length Q r� 'D' Box APA_ Type Filter Material epth Filter Mat ial �_8___________.......................... Distance to nearest: Well ___----------------_---- Foundation ------___-______-_---_ Property Line ____..._.____.._.___ SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ j'ej Water Table Depth ------------------------------------------------Rock Size -------------------------------- k Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ____...._.._.....\_Is REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ______--________-_---_--_________- Se tic Tank (Specify Requirements) ________________ Disposal Field (Specify Requirements) SQ-- )--4Q- --- Y ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ---------------------------------------------------------- ------------------------------------------------------------------------ (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 or hick this permit is issued, I shall not employ any person in such manner as to b e s b' ct to Workman's o pe sa ' n laws of California." Signed ____��!��G. ._.____ .______ _____ Owner --- - ------- --------- --- - By -------------- ------------------------------------------------- ------------------------ Title ---Q_W_VV_ -------------------------------------- (If other than owner) F R D ART NT USE ONLY APPLICATION ACCEPTED BY _- - - ----- ---- -- - -- ----------------------- -------------. DATE ---1174571-t- -- --------------- ---- BUILDING PERMIT ISSUED -.__--_--__ -- ----------------------------------------------- ___.___-_____--_.__________._______,---- ADDITIONALCOMMENTS -------------------------------------------------------- --------------------------------------------------------------------------•-------------- ------------ -------------------------------------------------- ----------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ ------ ----------------------------------------------- --------------------------------------------------------------------------- ------- --------------------------------- - ---------------- - ----- -- ---- --- -------- - -- - - - - - - - - - - - ---- - ----------------- -- ------ -------- - - --- ---- --- - - -- -- - - - 47 Final Inspection by: . ---------------------------------------Date --o�-1 - " SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M