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FOR OFFICE USE: PPLICATION FOR SANITATION PER' 4 �. . (Complete in Triplicate} Permit No. _ ...... This Permit Expires 1 Year From Date Issued Date Issued ---------- Application _ :.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/LOCAT N � 7 ycC .-CENSUS TRACT Owner's Names _._ c ....... �� - 5: Phone cc _ Address 9C_-- .. isn 't e'� rl< Z CitY � Contractor's Name _ ------ �i.. a--+�-s,-�-��. _ - ---`-`�..- -_*� � �2_-_License # Phone ------ Installation --Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other Number of living units: ------- Number of bedrooms -.----------Garbage Grinder ..._ ______ Lot Size ..... -n�J :cs -._----_-. Water Supply: Public System and name ----- -------------- .-.-___ -- Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Cf ay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material - - ------- If yes, type ------- ----.-_---. (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 [ ] SEPTIC TANK'[ ] Size--------------- - .----------.------ Liquid Depth --------- ----------.----- Q Capacity ----- Type ------------- Material- ---- ---- ------ No. Compartments ----- ---------------- on Distance to nearest: Well --- .. ___--.-.Foundation - . .. ............ Prop. Line -.-----------__------- LEACHING LINE [ ] No. of Lines --- ---------- . __ Length of each line-.... .- ---.__- - - Total Length .-.----------------------- 'D' Box _ _ Type Filter Material -------------- ..._Depth Filter Material . ..____..__._----_-------_---------------_- Distance to nearest: Well __ _----__---__-----____ Foundation .... .... Property Line ...----.._-_------------ SEEPAGE PIT [ ] Depth ---- --. .-- Diameter .-.- -------- Number _ ------ ----------- Rock Filled Yes ❑ No ❑ Water Table Depth --------------------- ----------------------- --Rock Size .................... ---------- Distance to nearest: Well .................. -----Foundation --- -- -- ---------- Prop. Line .... ----------------- REPAIR/ADDITION(Prev. Sanitation Permit T# --------.--------..................... .. .. Date __....-----------.----------------) Septic Tank (Specify Requirements} . ... ... ............. -.....------------------ -------- I— - -- ---- -- ------- ----- - ---------------- Disposal Field (Specify Requirements) ------------------------ --- -------- -- ---- ..... . . .........-.. (Draw existing and required additilVn on reverse side) I hereby certify that 1 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 becomes eject to Workman's Compensation laws of California." Signe - C' .. .. ......... ._(.-. .... .. --- ..._.- Owner, 11 '� , G, - _- D LK-I �_-- - -------------- Jitle (If other than owner) FOk DEPARTMENT USE ONLY p APPLICATION ACCEPTED BY DATE BUUDINC- PERMJT ISSUEDDATE ......... --. .... .. .... .... HDDITION,.V_ C:I MMENTS . .... -- -- . .. .................. - -- -- -- Final ?nspecticn by: Dat V-- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 ;-'68 Rev. 5M