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FOR OFFICE USE: f A APPLICATION FOR SANITATION PERMIT ------------------------------•-------------- ---- s (Complete in Permit No. J/ _--------------- fi This Permit Expires 1 Year From Date Issued Date Issued _ u16- � i 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: ' JOS ADDRESS/LOC N &YV... --- ��-- --------------------------- ---------------------- ---CENSUS TRACT ------------------------- Owner's Name _.- } �.-�------- --- ------ - -- -- ---- ----- ---------------------------------- -------•---------- - --Phone ------------------------------------ Address ----------- -- -- -- ------------------•-•- Address0 le { Y. City - ---- - - - _ Contractor's Name art=,;o_ �- _ �..n r. r_ _- .. License # _ 3 Phone -- --------- - Installation will serve: Residence Apart ent House❑ Commercial:❑Trailer Court !❑ f Motel ❑Other" _ ._ .- Number of living units:_._.-� Number of bedrooms _� -._Garbage Grinder _.___-____ Lot Size ---4-9-7c Suplyt PubiSstem and=nae -p ------------- --------------------- - ------Private i Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam P Hardpan ❑ Adobe ❑ Fill Material _____________ If yes, type ----------------------- (Plot -___________-______-(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 [ j SEPTIC TANK![/] Size------------------------------------------------ Liquid Depth ----------------- --------- CapacitYL. # Type -------------------- Material---------------------- No. Compartments -----------= - Q4 D star eiTto nearest: Well ------------------------------------ Foundation -.-----=---�--------- Prop. Line --------------•------- LEACHING LINE [ j No. of Lines ___________ ____ Length of each line--------------------- ---.__ Total Length D' Boxy:__-- r--- Type Filter Material --------------------Depth Filter Material --------------------------------- Distanc�Barest: Well ------------------------ Foundation ---------------------- - Property Line -------------- - 1! SEEPAGE PIT [�]:.,,,�:;,� .,Depth -----I-------------- Diameter ---------------- Number ------------------------:--- Rock Filled Yes ❑ No � 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) ---------------------------•- ------------=------------- -------------------------------- _ -------- --------- ---------- - ---X :.:., r ----- ------- ------ -i - - - - - --------------- VfDra exsting and wired 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, ci"d 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 not employ any person in such manner as to become su to Workman's Compensation laws of Califoniia." Signed ------. Owner $Y (Ie ---- -- - L--------------------------------- -Titl ►�_7':L ,ra ,t .-- : ------------------------ ---------- (If other than owner FOR .DEPARTMENT APPLICATION ACCEPTED BY -- ----------- BUILDINGDATE�_--------- ------ -- ---------�U%ISIEOINLY ---------- --------------PERMIT ISSUED --------- }----- --------------------------------------------------------------------- -------DATE ------- -----•----------------------------- ADDITIONAL COMMENTS _---------- # - = -------------------=--------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ - ---------------- --------- ------------------- -------------------------------------- ` R a --------------------------- ----------------------------------- ------ ------------------ ---=-=---------- --- Final Inspection b _ - --------------Date - ---�- =---- SAN JOAQUIN LOCAL HEALTH DISTRICT ., E. H. 9 1-'68 Rev. 5M