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' FOR OFFICE USE: o A PLIP CATION FOR SANITATION PERMIT - --- -------------- -------------------------- 3-0 (Complete in Triplicate) Permit No.AV This Permit Expires 1 Year From Date Issued Date Issued � D ------------------ - --------- ------ 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 5ompliance with County d' ance No. W and existing Rules and Regulations: JOB ADDRESS/LOCATION ,�A _ _0- ___CENSUS TRACT _-_.------------ Owner's Name ---------- - Pho a . 3L-�.�- Address ---------------------- ---- City -- - Contractor's Name ______ _____ __ __ .___ __________ __ ----- _ __ . _-- --____________.License #l0e-S--I-___ Phone4-�1(o-�1-rZ Installation will serve: Residence%Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number -- -----------------------------Number of living units:----I------ Number of bedrooms __✓___Garbage Grinder -1V0--- Lot Size _/Q0_X_._2�rr.�9-------- 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.) 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 ------ Length of each line--__- ---------------- Total Length _----------------- 'D' Box ------------ Type Filter Material ___________________Depth Filter Material ----------------------------- -------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------_--___._____ SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number -------.---- --------------- Rock Filled Yes ❑ No i❑ Water Table Depth ---------------------------- -------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -.-____.__._._.. --- Prop. Line -_---__---,___---_..__ REPAIR/ADDITION(Prev. Sanitation Permit# ...lJ_-.15.)4,VC0 - Date ___---_---------------------------) Septic Tank (Specify Requirements) --------------------------------------i-------------------Z-- --------7----------------- ---------------------------------------------57 - posal Feld (Sp ify Reoquirements) ----------- ------- --- / --el------------------------ - /).� moi.--ted--------•- ?r-- - -------- ----------------- ------------ ------------------- - --------------------------------------------------------------------------------------- ---------------------------------------------------------------------- --------------------------------------- (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 th in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to beco a ubject tg W man's o ensation laws of California." Signed ---- ° - Owner r�------ BY - itle -- ------------------------------ If - ( other than owner) 0 FOR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY ____j061,, -------------------------------------------- DATE BUILDING PERMIT ISSUED ----------- 1-� - DATE ADDITIONAL COMMENTS -----------8.5----. - -- -------------------------------------------------------------------------------- ----------------------------------- --------------------------------------------------------------------------------- ----------- -- -------------------------------------- -------------------- ------------------------------------------------------------------------------------------------------- --------------------------------------- -------------------------------------- ------------------- ----- ----- -------- - ------ ---- ------- Final Inspection by: -- Date S- j ----•------- - ----- ------------------------------------------- -- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M