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FOR OFFIC - APPLICATION FOR SANITATION PERMIT / (Complete in Triplicate) Permit No. ----•------- ------ This:Permilt Expires 1 Year From Dat*Issued Date Issued ..G' f Applica " ereby made to the San Joaquin Local Health District for .a permit to construct and install the work herein describe . This application i d ca plionce ith County Ordinance No. 549 and existing Rules and-Regulations: JOB ADDRESS/LOCATION .................................. ....i_..............:... r .....CENSUS TRACT ................ Owner's Name = '" Phone Address ' a ..................City r i T A�.................................................. , Contractor's Name _09 - -_ ... . ...............License # _30.&V.4.9.. Phone Q InstblMtion will serve: Residence Apartment House f] Commercial OTrailer Court IZ Motel ❑Other............................................ "Number of livingunits:_ _ Number of bedrooms _. _.__ + �---- �S Garbage Grinder ..f�Q Lot Size : .V.i P,..JT Water Supply: Public System and name ---•-• --------------- ....................................................................................Private� �l Character of soil to a depth of 3 feet: Sand Silt❑ Clay 0 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 nide.( NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,( �r ! PACKAGE TREATMENT ( ] SEPTIC TANK ] Size.. +�....x.-•+ ..-------•-_- Liquid Depth . ............ Capacity _&4'40_.___ Typ�r�'� _ Material.00.-e "t*t,7.`_' No. Compartments --��-.--............. r • Distance to nearest: Weil ___ . ..._. ��f,�: - Prop. Line .451d-.�.._..-. Foundation . LEACHING LINT~ [ j No. of Lines -_-_. _____________ Length of each Zine..._ ` g �-•9- Total Length .`�/0.............. 'D' BoxType Filter Material I----------,-.Depth Filter Material _.. .._�.............................. i Distance to nearest: Well ........... Foundation _/V7.3V.......... Property Line _6'13. ......... SEEPAGE PIT { j Depth __-.--..�------ Diameter ._._.._..:� Number ...............:............ Rock Filled Yes ❑ No ❑ Water Table Depth. .......... --::-_----•--.._- .........Rock Size -------- ................... Distance to neaPesti Well _____________ -..--... --.._foundation --- -- Prop. Line ........................ REPAIR/ADDITION(Prev. Sanitation Permit# __------------------------------------------ Date ........-•_---._._----------.---_-} SepticTank (Specify Requirements) ...!------------------------------------- ---------.....-•--------=----•..-.........._....---------••---.._-.,.__..._.._._:.._...---•••... t 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 Joaquin County Ordinances, State Laws, and Rules-and Regulations of the San Joaquin Local Health:Distdct. Home owner or licen- sed agents signature certifies the following: "I certify that in the.performonce of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .............• :................•------------------------------------------------------------- Owner . By --- � `--- ' -C'�t mirk *........................ ------------------- Title ----------- - - (If other than owner) FpfDEPAJKMENT USE ONLY ' APPLICATION ACCEPTED BY G,, --------------- DATE BUILDINGPERMIT ISSUED ........---------------------------- .......................-._-------------------------------------------DATE -... ............................. ADDITIONAL COMMENTS -------------------- ---------------- --------------•_-_ -... ------------------------------------- -- ..----•---.. ------------------------------•------------��S4AJOAQUIN -- ---- ---- -- Final Inspection by: ••---------• - ............................. •--------•...........:...Date ...f -�� EH 13 2!� 1-65 v. LOCAL HEA.LTH DISTRICT 8/74 3M