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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT !Complete in Triplicate) Permit - 3 ................ ........ This Permit Expires 4 Year From Dat*Issued Date rtil0 �E, X71 - �-0 - Z / Application is hereby made to the San Joaquin Local Health District for a permit to construi:t and Install the work herein described. This application is mad n compliance with County Ordinance No. 549 and existing Rules and regulations: JOB ADDR SS/LOCAT1 3.........v-:,'!�_- C T� ............ r e� ,..,.. .�,.a l`.r�Y'�� � C NSUS TRACT ._...._..,................ Owner's Name ...._...1� ._.... P . ._......_-�.AJC'.l:.�1_.Cr:rr✓`..�..................... .... Address � Phone h.4 _./'� 1..1... "dG .E azo i �. ..................................... City ... . ...._.......lo Contractor's Name ................�e�.�_ _._................... ...........................License .. Phone Installation will serve: Residence❑Apartment House Commercial❑Trailer Court ] r = Motel ❑Other .... Number of living units............. Number of bedrooms ............Garbage Grinder Lot Size Water Supply: Public System and name ______________ ..Private's' Character of soil to o depth of 3 feet: Sand 0 Slit❑ Clay ❑ .Peat Sandy Loom 0 Clay Loam.0 t Hardpan ❑ Adobe ❑ Fill Materiel ............ If yes,type (Plot plan, showing size of lot, location of.system in relation to wells, 'buildings, etc. must be placed on reverse side i NEW INSTALLATION_: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT . f ] SEPTIC TANK PF Size._!__ `..' .._? _ .$?`?:x.�-0 Liquid Depth ........` ..? ...-------- Capacity --------- ----------- Type -------------------- Material. _ti^s. _.. No. Compartments Distance to nearest: Wel! /B4f Foundation ... .Z.�..... ... Prop. Line .......................` i LEACHING LINE ( j No. of Lines ---------------------- Length of each line.........................:... Total Length i 'D' Sox .----------- Type Filter Material ....................Depth Filter Material ........................ Distance to nearest: Well .._...._--.._.1........ Foundation Property Line ........................ 1 IT . #e /dd O Depth ' r, :_. Number .0a --- • - � -•�-. �.-.:. Rock Filled Yes '� No ❑ . r Water Table Depth .................. ............. Rock Size •--- :! '�� • Distance to nearest: Well ---------.�.a(Q ..------- .... ....... 1 .. Prop. Line .... .5 Date ........................:.......__-REPAIR/ADDITION(Prev. Sanitation Permit# -------------------_------- Septic - ---------------- ---- Se tic Tank (S ecifY.Re uirements) ) ...:.................. .......................................................... Disposal Field (Specify Requirements) ........................................ ..............••----- --- I ----------------------------------------------------------------------------- ------------- -------------------•- ...................___.............. ----•---------...... .-..........=..............................I__.__.......--- ----.... .............. � { (Draw existing and required addition an reverse side) f I hereby certify that i have prepared this application and that the work will be done' In accordance with San Joaquin a 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: j "I certify that in the performance of the work for which this permit is.issued, l shall not employ any person In such manner as to become smblect t Workm s Crimp ation laws of California." Signed - ------ ----------•-------------------------- Owner BY ..-•...... --- ------------ ----- Title --------. --- ............ (if other than owner) O , PART ENT USE ONLY y APPLICATION ACCEPTED BY ------ DATE ,.:_. �. l Y,_� • 1 - - BUILDING PERMITASSUED -� - _... _ ADDITIONAL COMMENTS ..-----------------..... ©ATI: ._.._....--•---. ------ ......... ----- --•--- --- ------- --------------------------- .- Final Inspection by: ---- -- _ ..............•• --- ------ --- -........Date .......... -- --Date ....1 .� .. � EH �3 24 1-68 Rev. 5 SAN JO UIN LOCAL HEALTH DISTRICT 7h 3M