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_ FOR OFFICE USE: APPLICATION ICOR SANITATION PERMIT 4 (Complete In Triplicate) Permit No. L ......._ .. . ■....... ....... ........' .. .. . - �..�.! ... . ... .Sf._.. P1 VV pate Issued — ............... .: .... .......... Thts Penult Expires 3 Year from Date Issued Application is hereby mode to the San Joaquin Local Health District for a permit to construct and Install the work herein described. This application iss mode in comp is ce with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA ION ...�'d..EIS_.._ _._ .1r-a�..�ii.e.e. 'i-- ..........................CENSUS TR ACT .......................... Owner's Name `. w J Phone �J Address . .f. City . r� Contractor's Name _--� ..License # .��. s .a-- h 4 -�- ..... Phone .............................. Installation will serve: Residence❑Apartment House ,Commercial{]Trailer Court 0 i Motel ❑Other... ............ f Number of living units:._------------ Number of bedrooms ............Garbage Grinder Lot Size Water Supply: Public System and name -•---------•---- ••..................-----..................--•----........-----..........---..................Private Character of soil to a depth of 3 fest: Sand❑ Silt❑ Clay 0 Peat❑ Sandy Loam e 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.) f NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TAMC ] Size:................................................ Liquid Depth S f Capacity ------------------•- Type _.._...__.--- ...... Material...................... No. Compartments .._.................... Distance to nearest: Well ....................................Foundation ...................... Prop. Line ......................[n LEACHING LINE j No. of lines ------------------- Length of each line............................ Total Length ............................ 'D' Sox ............ Type Filter Material ....................Depth .Filter Material ........................................... Distancelo" nearest: Well _-_---------------_- Foundation ........... Property Line ................. SEEPAGE PIT (•j;� ' Depth .---=-•--- ------ -Diameter ---------------- Number ........_.................. Rock Filled Yes ❑ No Q-% �� .�.. Water Table Depth ....---•...............................•-----_Rock Size ................................ . N Distance to nearest: Well -----...._.............................Foundation .................... Prop. Line ............. 'r REPAIR/ADDITION(Prev. Sanitation. Permit# ............................................ Date .................................. Septic Tank (Specify Requirements) --------- ................................................... ....... ._... Disposal Field (Specify Requirements) .. .. . .... . ....� _ ._ ._e d - .6. s ---------------- radGexisting an equired addition on reve a side) 1 hereby certify that I have prepared this application and that the work will be done in accordance with San .Joaquin F County Ordinances, State Laws, and Rules and Regulations of the San .Joaquin local Health.District. Home owner or Itcen- i 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 I as to become subject to Workman's Compensation laws of California." II Signed ----- • ---------------- Owner ¢ •---------------•--•• BY • --- .. _ Title ... .C� . s (if other than owner( ' FOR DEPARTMENT USE ONLY -APPLICATION ACCEPTED BY --------- -----------"----- .... . 7�f -•------------------- ------------ ---.._.. DATE _ ._ .. . BUILDING PERMIT ISSUED .___ •. _ TE ...............•__....._--- ADDITIONAL COMMENTS o .t ... �j' _.. �.. It39� ------------------------------ --- .. FinalInspection bY: .. ."_........ ----•- ----- Oate .... .. ........ ......... EH 13 2!t 1-68 11ev. i SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M