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aj -.?'. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------- ------- ---------- ---------- ----------------- (Complete in Triplicate) Permit No. -_l�1�11 ____ This Permit Expires ] Year From Date Issued + Date issued - 7.74 p 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 acid Regulations: JOB ADDRESS/LOCATION __°�.3.7i __a_�- _____ L_n__V_____ __ __-__--. h_�. © CENSUS TRACT Owner's Name d ----- -------- f --------------------------------------------------Phone Address --2-3-7-1Y----- Clu_c---- lnN-�=------------------------------------------ City --------- --------------------------------------- ------ Contractor's -----------.License # A- --- + _" _ Contractor's Name --------- __��r-_�_-�_ --*.P---------------------------------- ��}'I�- Phone � Installation will serve: Residence M Apartment House❑ Commercial :❑Trailer Court [] �Motel ❑ Other .------------------------------------------- ��,/ Number of living units_____________ Number of bedrooms _______Garbage Grinder ADI --- Lot Size e _- ------------------- t Water Supply: Public System and name ----------------------- ..---- ------------------------------------- _IPrivat Character.of soil to a depth of.3-feet:- ;Sand WW Silt-E] Clay ❑ Peat❑ Sandy Loam -❑-_ Clay,Loam:❑� Hardpan ❑ Adobe'❑ Fill Material F 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 sewer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK'[ ] S' e__________________ _ _ _.______ Liquid Depth ____________________,_ Capacity -----------------• Type ---------- Material-------------------- - No. Compartments ---------------------- Distance to nearest: Well ________ __________________________Foundation _ ____________________ Prop. Line _____________.__---_-_ V ' LEACHING LINE [ ] No. of Lines ------------------------ L gth of each line------------------- .------ Total Length ---------------------------- 'D' Box ------------ Type Filter terial --------------------Depth Filte Material --------------•----------------------------- Distance to nearest: Well -- ________-__________ Foundation ___________ ___________ Property Eine ________._______........ SEEPAGE PIT Depth Dia ter ________________ Number -______________ ________-___ Rock Filled Yes No [ ] p ------- - --- ❑ 0 Water Table Depth ------ ----------------------------------•-----Rock Size - ---------------------------- Distance to nearest.W --------------------------------------Foundatio ' ----`------ --.---- Prop. Line --_------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ------.------------------------------------ Date -----------------------------`--_I TA Septic Tank (Specify Requirements) ----------------- d,--------104 -----�---1—#e{i-�-1------- /�/1f-�= � ��-----•----------- Disposal Field (Specify Requirements) AZF .45'/glIRr�----------�¢'�,-< t--------------------------------------------------•--------------- (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 riot employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed �` ------ Owner ------- ------ (If other r} han owne ------ ---, Title ------ --- -- ----------- -------------------------------------------- r p FOR DEPARTMENT USE ONLY 00, APPLICATION ACCEPTED BY -----#_g- a-------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED ------------ --------- I—----------DATE-------------------------------------------- ADDITIONALCOMMENTS -- ------ ------------------------------------------------------------------- ------------- --------------------------- ---------------------------------------------------------------------- ----------------------=----------------- ------- - ------------------ --- = -- - ------------------- ___ - - 1 ----- --- -------------------------- - ------------------------------------------------------------------ Fi l ------- tio-------- -- -- --- -- ----- - --- ---- --- ----------------------------------- -------------- Final Inspectio Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H, 9 `¢1:-'68-Rev. 5M