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FOR OFFICE USE: APPLICATION FOR`SANITATION PERMIT (Complete in Triplicate) Permit No. ______________________ �__ ---------------------_ This Permit Expires 1 Year From Date Issued Date Issued __��5 �� 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 _5944-3.1----- r----- --------=------------- -- CENSUS TRACT --------------............ f Owner's Name - tv I\ 1 1-- lit_` _� °:�Ol' -- --------------Phone Address __ _ - -- 1 `Lo---- �-�r—� �' f �t - - _ ' City 1 Lam--< -o-�-----------=-- ` Contractor's Name --------- �--1--�----------------------------------------------------- --------License # ------------------------- Phone ------------_--------------- M Installation will serve: Residence WApartment House,❑ Commercial :❑Trailer Court ',❑ Motel ❑Other / . �. — Number of livingunits:______ ____ Number of bedrooms ___- Gorba e Grinder 'IN pper�:. ------ Water / ____ g _Sit Lot'Size _ - Water Supply: Public System and name -------------------------------.----------------------------------------------..--------------------------------Private j 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.) w NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT I ] SEPTIC TANK. j Size____ _ � nn__a_04.I_�_________ Liquid Depth __._.._---________________ r Capacity ,Type �'Q"e��MaterialCDtt !�_h��No. Compartments ----�=______________ ._. . r ,,..ss 2��I ' Distance to nearest: Well ,e�,�7__�_ __:_______Foundation _�__U�__'��___ Prop. Line __ _ _____ ___ LEACHING LINE f ] No. of Lines ------�----------- Length of each line-----�?d__ ___ Total Length D' Box Type Filter Mate Depth Filter Material ___f_J' 1L �' _ r-lu ( y Distance to nearest: Well _ _ Foundation fQ_ _ _____ Property Line __a ��"r.l. __ .;- SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock-Filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ________-__________-__ REPAIR/ADDITION(Prev. Sanitation Permit# ------••------------------------------------ Date --------.-------------------------) SepticTank (Specify Requirements) --------------------------=----------------------------------------------------------------------------------------------------------------- Disposal Field (Specify Requirements) ______________________ _________________-______________ ----------------------------------------------------- ----------- ------------ ------------------=--------------- --------------------------------- __(Draw existing and required addition on re'verse'side) V I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin r County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen- A 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 toWorkman's Compensation laws of California." Signed _. .____ _ _ - --- ------ - ------ - -=L)---------------------------------------------------------------------------------- Owner 4 By -------------- ----------------------- ---- ,. ----------------------------------------------- Title ---------- -- (If , other than owner) �. F ARTMENT USE ONLY t APPLICATION ACCEPTED BY _ -- ---- ----- ----------------- ------------------------ ---------- DATE -----/ = -171---------- BUILDING PERMIT ISSUED - DATE -- ----------- ADDITIONALCOMMENTS ---- --- - ------ ------ - ---------- - ------------------•------------------------------------------------------=------------------------------------ ------- ---- -- ------- ----- ., Final inspection by: -------------- --- ---------------------------------------------------------Date - � ------------------ AQLI LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M +