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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) r�! /5 3 ......_...._�.............................. Permit Na. _.`.?.. _..�_.._...... ...............................................-......... ........................................................ This Permit Expires 1 Year From Date Issued Date Issued .3:5L�. 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: JOB ADDRESS/LOCATION .....,j ..,6.7_q�._.._.....•.... _.._-v. l. S CENSUS TRAC 'S - --------- _ _.. Owner's Name ......CLC-69-a...... PE------.M,J-.I~iC?.5-•................•-••-----...,----........_..............._... ....Phone --------•--•..---...... ............ Address ti .05�-.. • 4....C: � � ! .......... ------- ..._........•---- Contractor's Name .......P.:t:........jrdk.e ......----------------............•................License # Phone ... .......................... Installation will serve. Residence ❑Apartment House❑ Commercial ❑Trailer Court E7 Motel00ther ---- ---•---•----...••--•................... Number of living units:_._....___ Number of bedrooms ----,3---.Garbage Grinder ------------ Lot Size ......_g,4.r-_______________.............. Water Supply: Public System and name ..............................=---------------------------------------------------------------------------------Prlvate�o Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat 0 Sandy Loam R] Cloy Loam ❑ .. Hardpan ❑ Adobe ❑ Fill Material .&0____ if yes,type ^ -----_........ J (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) ION: (No septic tank or seeps pit permitt d if public sewer is available within 200 feet,). PACKAGE: TREATMENT [ SEPTIC TANK ize�. q2 ............... Liquid Depth ...... ............... Capacity ---- Type Material__. 'NzQEi6. No. Compartments ....Z........... � ee2-� _._..Foundation ..---i()-' 3 c�; 6 istance to nearest: Well .._......_R_________________•- - - -•-----.... Prop. Line ----.•- - ........... LEACHING LINE OZ No. of Lines _........ _..--- .... Length of each line.----...-j0..---------- Total Length ...._, �...... ..... � 'D' Box .....I..... Type Filter Material .-&X A-----Depth Filter Material ......yl.1�............................. . Distance to nearest: Well l.D ... __.-...__ Foundation ..._.25� 50 � ._ ......._-- Property Line .... ........./..G SEEPAGE PIT [ ) Depth• .................... Diameter ................ Number ...........•------I......... Rock Filled Yes ❑ No ❑ Water Table Depth -----------•--- ................................Rock Size -------------------------------- Distance to nearest: Well ........................................Foundation ...---------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ..................................•----..... Date ..................................I Septicrank (Specify Requirements) ................... •--•-------------- .....................-............-........--..............................•............. DisposalField (Specify Requirements) ...---------•--•---•----••.............................•-----••-------------------------•--- ......................................... ------------ ..................-.......---.............................................- -------..-.-..------•-••-•-•---------------------------------------*..........• ........... ------------- --------- ---- ........................ -------------------------------------------------------------------................ --------...----------------•-----•----------•--- (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 not employ any person In such manner as to become subject rkman's/Cpmpensation laws of California." Signed ..... fc. L ....................... :.........:....... Owner By ..... ......................................... __.. . (If other than owner) FOR DEPARTMENT USE ONLY ...: ..� .� ,. APPLICATION ACCEPTED BY -----�t.h.�.Q•---------- DATE ----------------•••-•---••---...-----...-----------------.. ......... BUILDING PERMIT ISSUED ------- -------------------•----•---•--......... • . • ADDITIONAL COMMENTS ........................•--•--•-•--•-•..._.......----•----•----..._....... ................ ............. ... ..._....---•--.._..:_.--.................---............................................................. ..............•...........�....---.... .... ................. ... --...._....................................................__.._....------- ._....._.._.. ..................................... .--• .. �J Final Inspection by: ..Date ... ....... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 241-'68 Rev. 5M __ 7/72 3 M