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FOR OFFICE USE: APPLICATION FOR SANITATION! PERMIT ----- --------- ------------------------ (Complete in Triplicate) Permit No. ...................... ............................ ....................................................... This Permit Expires I Year From Date Issued Date Issued .. �.��...^T S' 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.;.2.4...... CENSUS TRACT .............:.......:.... Owner's Name r- R! `S t�Jlt. � j'.,....:..................................:.....................Phone �4.G?. ..._ Address 1�, ... ....... 4.514:....................................:... ::... City . J-Q.!;�I<t-avv---------.. .........:.............. Contractor's Name .........................••--•.........I............................. ..........2: . .license # ........................ Phone .......................... Installation will serve: Residence C❑Apartment House-❑ C6mmercial,❑Troiler Court i❑ Motel ❑Other ..!! ry':: l - ..h. rt Number of living units:...------- Number of bedrooms _: _;_,_GaYcge Grinder ------------ Lot Size ___________________________________ __...... Water Supply: Public System and name ..........:................ ...... :...................................................Private ®" i� Character of soil to a depth of 3 feet: Sand❑ Silt[] Clay ❑ P i Sandy Loam ❑ Gay Loam JH p ❑ ❑ . If yes,type ----------•--------- ------- (Plot an Adobe Fill Mqt � (Plot plan, showing size of lot, location of. system"'in relation, tow li buildings, "etc. must be placed on reverse side.) 9- S NEW INSTALLATION: 1No septic tank or seepage'p t.,permitted if,.p' Tic sealer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANKK Size.___.-----.••-• .. :...... ...... ......... Liquid Depth ..................... Capacity � ►Q. ,_- TypeSz�"�Materiai': No. Compartments ...'. -............. _ 1" Distance to nearest: Well ...... .. ...........4...."..Foundation G ............ Prop, Cine ._2Q .. • 4' LEACHING LINE No. of Lines _____________ Length of eacI4 line-q. 0----------__._-_._- Total Length ..../.041? n ' , IV D,fiBox~ ,C"� Type,Filter Material �__/C� \__Depth Fil#er,Ulaterial .....17.............................. Distanc to nearest: Well .../__ ....... Foundation ................. Prope ......-:-_-_ N SEEPAGE PIT . [ )M Depth .-------------- Diameter ---------------- Number ...... 1.............. hock Filled Yes ❑ No Q;:7 Water Table Depth ..:_.------------............. .................Rock.Size ................................ v+ Distance to nearest: Well ----------------------------------------Foundation .................... Prop. Line --------__..__.._....�' 1 REPAIR/ADDITION(Prev. Sanitation Permit# _. Date SepticTank (Specify Requirements) ----------------------------------------------------------- ----------.....................................--------------•---------------- Disposal Field (Specify :Requirements) ...............:.. ' j --.....----•-......••--••............. -----•-•-• ---- x .-.----............................................................................................ (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin k 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 to Workman's Compensation laws .of California." ' Signed _. e _. ' ._ .. ........................... Owner By --.................. ........... ••--••--•-----..............._ ... Title (If other than owner) d FOR DEPARTMENT USE ONLY -fit..._ v�--�---- 2 ............... .. APPLICATION ACCEPTED BY........... 7: --___-• ------ ----------------------•----.... DATE ._f2_ ___--� � _ BUILDING PERMIT ISSUED .... :........:... - --• . ........... -------•.................DATE ........................................... ADDITIONAL COMMENTS .'.'?- .... .. .. .... ......................•----•--- -- ....... ________________________________________ ...._..:._. ....... _. ___ ....... Q _.. - ..... Z Final Inspection by: .............Date ...... SAN JOAQUIN LOCAL HEALTH DISTRICT )� i t E. H.1.3 24 1.'68 Rev. 5M 7/72 3 M