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'FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ..,...... �lJ (Co mplete In Triplicate) Permit No.................... . .......... ......... This PermitExpWs 1 Year From Daft Issued 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 .s " / T JOB ADDRESS/LOCAT�IO''N _- 7 �'l R ; .V ........ !/l.J .....CENStJS TRACT ...'��.............. Owner's Name .....1..A-k'1-/�-__,/G��/ ............................................:................Phone J ,3.77,rff.11Y_ Address -..-.SIS}.M. 11:�....al,60,0. -•--- Contractor's Name s, 1 .-----•-------•....................................................License# .......... Phone ---W...4.........._..... Installation will serve: Residence E9 Apartment House fl Commercial OTrailer Court 0 Motel(]Other............................................ Number of living units:--/------- Number of bedrooms ..-I.....Garbage Grinder Lot Size ........ .. ............. Water Supply:Public System and name ........................................................_._..............--_........._ _._..__.._......._._.Private, Character of sail to a depth of 3 foot: Sand E] Silt 0 Cloy Q Peat❑ Sandy Loom❑ Clay Loam` Hardpan❑ Adobe fl Fill Material............if yes,type............... ............ (Plot plan, showing size of lot, location of system In rotation to wells, buildings, etc. must be placed on reverse side.) R NEW INSTALLATION: (No septic tank or seepage pit permitted if public LLtcewer is available within 200 feet.} PACKAGE TREATMENT [ ] SEPTIC TANK ] Size ....../1 . Liquid Depth .../ (� �l Capacity .11.0 Typeji Materiae. .._ No. Campomtments . .... .r-�... 6 Distance to nearest: Well ....................Foundation .,t�Q.. "...... Prop. Line ...16712.k 6` LEACHING LINE [ ] No. of Lines ---- '------------- Length of each. line...--qx�................ Total Length _ ___._..........� 'D' Box ....1..... Type Filter Material ....1_'�,_,i.....Depth .Filter Material .._..�.� ............... '�• Distance to nearest; Well ..AQq_--------- Foundation Jfi................. Property Line ...1'�......_..........a SEEP Depth .................... Diameter ................ Number ._..._,_____.............. Rock Filled Yes ❑ No ❑+ PF W IF Water Table Depth ................................................Rock Size ................................ Distance to nearest: Well .... . ............... ..... .......Foundation .................... Prop. Line ................... REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date .................................. Septic Tank (Specify Requirements) -----••... •-.._.._.._.. .............. .................. ......................................_................. Disposal Field (Specify Requirements) - ........................ --------------------•--- ....--•----------.-•----•-------••-----•--_---- --------..............._............---:......._.._...._.-----.....-•-..._........_----.......... (Draw existing and required addition on reverse side) I hereby certify that l have prepared this application and that the work will be done In accordance with San leagnM County Ordinances, State Laws, and Rules and Regulations of the San Joaquln Local HeoW,District. Nemo owner or licomw sed agents signature certifies the following: "I certify that in the performance of the work for which this permit Is issued, I shalt not employ any person in such manner as to become subject to rkman' Compen on taws of California." �..�� Signed ' ?/ .._. � f-�� '"'�' � --•---- .._._ Owner By ---- ...................................... -----....... ............................................ Title ........... --- ------------............_......_...._.._.....__..__.... (if other than owner} . f, R WVARTMENT.USE ONLY APPLICATION ACCEPTED BY_ . DATE .. _. ..j`"_, .. ._ .......... BUILDING PERMIT ISSUED ...... ---- .............DATE ... ...._._._......-----., .,...._- .......... ... ADDITIONAL COMMENTS ---- ------..". _..................... ............. ....... --- --------- Final Inspection by: ..... s.. / -' ..... Date 4.-- f EH 13 2h 1--68 v. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8 7 3M