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FOR OFFICEVSE: f APPLICATION ICOR SANITATION PERMIT r ...................................•.._...........---•--- Permit No. fCaanplete in Triplicate) ------------------ , .. . This Parntlt Expires 1 Year from Date Issued Date Issued /L=J 7 J 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 Na- 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION ... _ ...... �:...QQ....... ...............................CENSUS TRACT ......................._._ Owner's Name ..------.A—,6 C ��.. ..!'� &AWC........................... .....................Phone 1 d Address A .� ,_.......-•••-...---• ' /•-- -----.City .....,�f1.�1.__ �,5.�-•-�-•-----•--•.............•-•--------- Contractor's Name . �. �.��._..��i �,��.-'�•--� �--•+��-----`------.._...Licrense d` Phone Installation will serve: Residence 00 Apartment House Commercial❑Trailer Court 0 Motel ❑Other....-------------....................... M..... Number of living units:-----�__--- Number of bedrooms ---A.....Garbage Grinder . .- Lot Size/00./,��. �.�..........._... Water Supply: Public System and name .................................____................_ y .................Private ❑ Character of soil to pth of 3 feet. Sand n Silt E] Gay ❑ Peat r_1Sandy loam ❑. Clay Loam ❑ Hardpan o Adobe 0 Fill Material ............if yes,type............... ............ (Piot plan, showing size of lot, location of system in reiation-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 204 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size...................................................... Liquid Depth Capacity -------------------• Type _-----•_-_---.. Material.-----... -••---••---- No. Compartments ...................... Distance. to nearest: Well ....................................Foundation ...................... Prop. Line ......................`Y LEACHING LINE [ ] No. of Lines ----_------------------ Length of each l€ne.._-_-!"............._..... Total Length ...A..................._..N D' Box .-_......... Type Filter Material .............; Depth Filter Material __ ....-•-••..................................f1 Distance to nearest: Well .........................Foundation*...................... Property Line ........................ SEEPAGE PIT { l Depth -------------------- Diameter _-..______-...:. Number ..-------.........._..__..__ Rock Filled Yes ❑ No C1 �� N Water Table Depth -••--•---•-••-•...............•---------•----...Rock Size ............................... Distance to nearest: Well ...._•................................ Foundation .................... Prop. Line ...................... REPAIR/ADDITION#Prey. Sanitation Permit# ............................................ Date -------------•------------.------_) Septic Tank (Specify Requirements) ----•--•••----•-•--------•-•---•..................................•-•-..........._...........•-•-...-•---...... Disposal Field (Spe ' Requirements) '-_-._ • ..._-----,- --------------------- -------- ---- • _. ..�Q (Drs existing an re re additi on reverse I hereby certify tha have prepared this application and that the work will be done in accordanu with San Joaquin County Ordinances, Stn a Laws, and Rules and Regulations of the San Joaquin Local Health,District. Nome owner or ficew 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 Workman's Compensation aws of California." Signed --------------------------- --------- - ----- -- Owner By ----- ------•-----• . Title ... 2��1e�r=1� . (If r than ow "EPA MENTr E ONLY APPLICATION ACCEPTED BY _ ---------- --- DATE . -. .�- ...-.-..-...---. . BUILDING' PERMIT ISSUED -- ---.......---..•. ----------------- -- --- ---_------------DATE -- ------ --= •- .. . . ............•--- ADDITIONAL COMMENTS --�jx.. ...... . ........... .. :..-.. ---------- - ------------- . Final Inspection by- ----------- -- ....-..-Date -.. --. ..- EH 13 24 . 1-68 itev« SA JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M 4� t 1