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FOR OFFICE US`E,� APPLICATION FOR SANITATION PERMIT ----------------------------- ------- (Complete in Triplicate) Permit No.._��_- a._ _. ----------------- -------------------- ---•-------------- k kN Date Issued �p-�3v-_7v ______-______--_-_______-____-______„_____________ This Permit Expires 1 Year From Date 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: JOB ADDRESS/LOCATI N /_4?I_d _3-.-__ t . -------------CENSUS TRACT _'. - _ -_ 107 . - P ---------------------------- -------Phone 4------- -Owner's Name Work -- -l. Address j City o00_V05;!0y2Z_?--A_1----------------------------- Contractor's Name -._ K /_ll---------------------------------------------.........License C _ Phone Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:--/------ Number of bedrooms ______Garbage Grinder - __._ Lot Size __�__ Water Supply: Public System and name _._._________._ -- _________________________________________Pri'vate Character,of,soa,depth of 3_feet: ,,__Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- (Plot -.-_.____________________(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 sewe is availablg within 200 feet,) 1_-4?, A X� ----- Liquid Li uid De th ” ..__-. PACKAGE TREATMENT [ ] SEPTIC TANK�[� " Size �...._ � q p -------- `` rll Capacityf�S&0Q__„__ Typ _ __ MateriaC0*'C,0VZ7_4C`No. Compartments Distance to nearest: Well _- (------------------------__Foundation /C�.-____-__ Prop. Line �� 100 ----.__._.. LEACHING LINE P""No. of Lines _ __ ----------------- Length of each! line---1740----------------- Total Lengthc; ./Q_________________ � D' Box Y � Type Filter Material C-&-- _s._FDepth Filter Material � .......................... Distance to:nearest: Well ---------- Foundafio`n A4P_/ - Property Line �'� ............. 77 _. ._ W SEEPAGE PIT [ ] Depth _____ ------------ Diameter --------- ------ Numberµ ----------------i--- Rock Filled Yes ❑ No i❑ Water Table--Depth ----_- -- •_Rock Size ` Distance to nearest: Well ________________ ____________________Foundation ------- _f------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------_----------------------------------- Date -_-____-._.__.__-_ ___ -_-.-_--- SepticTank (Specify Requirements) -------------------------------------=----------------------------------------- --------------------1-------------------------•-- Disposal Field (Specify Requirements) .__--__.__. -_. --------------------------------- --------------- ------------- ------------------------- ---------------------------------------------------=------------------------------------------------- (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 emptily any person in such manner as to become subject to Workman's Compensation laws of California.” Signe -- ---- ---------- Ovwne By --- � t �L = -------- ----- ------- ------- Title �ri�' - J - /4 ------------------- K -------------- (�er than owner) ...FOR._D0ARTM' NT USE ONLY. APPLICATION ACCEPTED BY --_- (.. _. ____-__ Z?-.=7 -_-. __ ----- ----------,DATE .' BUILDING PERMIT ISSUED ------------------------- ------------------ --------------------- ------------- - -- ----DATE ----------- ,--------------------- ADDITIONALCOMMENTS - ----- - ----------------- ----- ---- -----------------------------t----------------------------`. ----------------------------------------------- ----- ------------------ -------- ----------------- ------- r --------- .. ... .... ... .. ___- -------------------- _ --- ___ i ._ ..-. ._._. .-. -------------------------------------- _ - - --------- . ® --_7 Final Ins ._. ------ - - bate - - �2 SAN JOAQUIN LOCAL HEA).TH DISTRICT E. H. 9 1-'68 Rev. 5M