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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete Permit No. .7s..(Completein Triplicate) _ .................... . ..................... Date Issued 7"7S This Permlt Expires I Yew From Deft 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 _ I � r JOB ADDRESS/LOC IONQ-- ��% . .. ----- --- i.. ..... . . -�...,. .....................CENSt1S TRACT .......................... .. . . .. ... . Owner's Name .....% ' ....................................*.................................... Phone Address ............City .. .................................................... Contractor's Name ......License# Installation will serve: Residence JVApartment House 0 Commercial❑Traller Court ❑ Motel❑Other............................................ Number of living units ..... Number of bedrooms --3....Garbtage Grinder lot Size 10W c:C'IL94,1.......--- Water Supply: Public System and name ..•...............•---.........................._......._....................................................Private) Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peau❑ Sandy Loam Clay loom ❑ Hardpan❑ Adobe❑ Fill Material ............If yes,type.......I....... ............ (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 f ] Size..../' �J O.�a� ... Liquid Depth ......,t................ Capacity .4_c4.... Type Moteriol d.o. PuZ7 No. Compartments ...; ............0 Distance to nearest: Well ......��.........................Foundation ..`0..........-... Prop. line -.100..;r�........ 04 LEACHING LINE ( ] No. of Lines .-c7—-_------------- Length of each line. 57. Total Length I;X4G 'D' Box .._ � l..-... Type Filter Material .;;L ........ Filter Material .......�................................. N Distance to nearest: Well ...�A�d,........... Foundation ..../.._0............ Property Line ...f..007...... SEEPAGE PIT O Depth .................... Diameter .................Number ................... ........ Rock Filled Yes ❑ No 0V Water Table Depth ..........•...-•-...._.•-•--.....•..............Rock Size ................................ Distance to nearest: Well ..............Foundation ....... Prop. Line ...................... REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date .................................. Septic Tank (Specify Requirements) ........ ............................................._................. DisposalField (Specify Requirements) ----------------•--•----.._.....---.........---•----•--._......--------•-•-......-------------•-•------...................--••-...... ------------------------------------------------------- ------...................................................................................................................I........................ •---------------- -------------------------------------------------•------------------------------------------......•...........---•-•--.........---------------------................................... (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. Mom* 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 shell not employ any person In such manner as to become subject to Workman's Compensation laws of California." Signed --------------- . .. .. .........•..._ Owner . By .: C�'C�' a�-p,�(�L ...-- --••--........_. Title ....---------- ---------- ` (If other than owner) FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _... ...... DATE ..__lt- -- -------- :- BUILDING PERMIT ISSUED ..................... ..................... . --•---.DATE .----.- -----.---------_--.....----- ADDITIONAL COMMENTS ------------ -- ...............-...... . --•-----._.....•-•.................... _--------- -------------_ ------------------ -----------• ...........-...................--... ---- -----....... .................... ---- ..........................._-_••-....... .......... ----------------- --- - - -------- --------------------•--•-- -----------------•............. --------•----- ------ -------------- -------------- .. ...�... Final Inspection by: . -- ... ...........-..---•- ..........-------•---............Date ....Z6." ... ...----- EH 13 2h 1-68 liev• 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7!I 3M