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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------` Permit No. (Complete in Triplicate) --------- --------------------------------------------- b, Date Issued ----------------------------------------I---------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the;an 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: - p T- �Gf C� /�L-4RP®I�PT itl ----------- ------CENSUS TRACT --- _. JOB ADDRESS/LOCATION _ w Owner's Name A-AWV------��17j 7-1V-------- --------------------------------------Phone f.-'-<`--�- .... ---- Address Q 1-_ /- .--.G.-/I-----Lc---------------------------- Cityr-ly�,�4A ,.SC04-!If' 7�------ Contractor's Name ----72L-x-=.QJ9/ ------------------------------------------------------License �25P-- Phone _'I. S Installation will serve: Residence [Apartment House❑ Commercial []Trailer Court l❑ 00 Motel ❑Other -------------------------------------------- 7 4 Number of living units:__[------- Number of bedrooms ._ ----Garbage'Grinder Lot Size _ _��'-- � ------------------------- Water Supply: Public System and name ___-------------- ___-_-.____Private Character of soil to adepth 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewej is av`a'ilable within 200 feet,) Z/ PACKAGE TREATMENT [ ] SEPTIC TANK:[AK Size,'3"kms+ .$Z -T " Liquid Depth -_ _____________ Capacity ----- Type Material04/407P, No. Compartments A................ Distance to nearest: Well ----- -----------------Foundation --------- Prop. Line .�.�_--___------__ LEACHING LINE [� No. of Lines �;2__-_____.__-__ Length of each line--, - Total Length ,47" .............. D' Box - _ Type Filter Material � � ___..Depth Filter Material _1-19_................................. Distance to nearest: Well --------------- Foundatipn' -/V---------------- 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 Tank (Specify Requirements) ------------------- ------------- ----------------------------------------- Disposal Field (Specify Requirements) ---------------- ._ -------------- -------------------------------------------------------------------------------N ------------------ ------------------------------------------------------------------------------- ________________________________________________________________________ ___y_ (Draw existing a6d 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 RegPlations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: j "I certify that in the performance of the work for w4ich this permit is issued, l shall not employ any person in such manner as to become subject to Workman's Compensation lows of California." Signed - ----x---------------- Owner BY el, '` ` = r--------------- Title -OM-Ay (If other than owner) FOR PEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- __x- _ ._`_------------ -------------------------------------------------------------- ' DATE r BUILDING PERMIT ISSUED ------------------- ------------------- -------DATE .-- ---------•----------------- ----------- ADDITIONALCOMMENTS --- -------- --- ------------------------------------- -------------------- ------------------------------------------------------- -------- -----------`-------------------------- ---------- ----------------------------- -- --------- - ------ - ----------------------------------------------- ----- --------------------------------------- ------------------------ - - ----------------- ------ ---- •------------ -- - - -------- ------ - -- ----- - --- - - Final Inspec i -0-------------- -------Date ---- --- --- 7 .•. e•�iG�J SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M G