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FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT - -- p p lete in Tri l° (Com Triplicate) Permit No.This Permit Expires 1 Your From Date Issued Date Issued ---16-- -. - -------------- 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.(bunty Ordinance No. 549 and existing Rule' an R uI tions: JOB ADDRESS/LOCATION .-----____--�o---- OU'r41------ -------- '�--- CK're--nl------CENSUS TIC -------------------------- Owner's Name - Z.- � iYARK ------------------------------------_1.-----------------------------------------Phone Q(oZ_-O �b--------- Address ---,33 (ct z�y........... .�f S - ----- Cit ST6eK Contractor's Name Ay-------K) ---%� --St%P0� -------License # -� �S�I--------- Phone '44--343 Installation will serve: Residence VrApartment House f-1 Commercial ❑Trailer Court ❑ Motel ❑Other -------------------------------------------- , t i Number of liv4ng units:--4 --- Number of bedrooms ---Z-----Garbage Grifnder J1�' --.-- Lot Size 5T__X-160----- ------------ 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 ❑ AdobeX Fill Material ------------ If yes,type ---------------------------- W (Plot plan, showing size of lot, IocatioA of system in relation to wells, buildings, etc. musr kfe placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] ISEPTIC TANK [ ] .1 Size-------------------------------.___•------------- Liquid Depth ._-_---_------._...-- Capacity ------------------- Type -------------------- Material-------------------- No. Compartments ------ ............... Distance to nearest: Well .-___-.__----------------------Foundation ---------------------- Prop. Line ----_-.------_---.- LEACHING LINE [ ] No. of Lines -----------------;--if--- Length of each line-------.-------------------- Total Length -_.--.__-.-----_-------. 'D' Box —--------- Type Filter Material .------..--_-_.---Depth Filter Aaterial -------_..---.---_._-_------------------ 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# -------------------------------------------- Date ---------------------------------- Septic ----------- .-------------------Septic Tank (Specify Requirements) ---------- - - - -----------E-------- Disposal Field (Specify Requirements) Dn e 33" x-2� P��- P - - - - ------------ ------------------------------------------------------------------- ------------------------------------------------------ (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 for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Com ensation laws of California." SignedTAl_ -N!C-t{� �11J9rtO Owner BY ----------- ------------------------------------------------------------------ - Title ------ -''� - ----------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY ! APPLICATION ACCEPTED BY ------ ----------------------------------------------------------------. DATE 1 �- - ------------- BUILDING PERMIT ISSUED ----- ------------------ -------------------------------DATE ------------------------ ------------- ---------------------------------------------- ------ ------------ ADDITIONAL COMMENTS ------------------------- ------ ------------ - ------------- -------------------f------------ ----------------------------- -- - -------------------------------------- --------------- ------- -------------- ------ --------------------------- ------------------------------------------- - - -- -------------- Final Inspection by: - -- ----- ---- ----------- ------------------------------ ------------ -------------._Date T —Date (S�oj ---------/// SAN JOAQUIN LOCAL HEALTH DISTRICT I E. H. 9 1-'68 Rev. 5M