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;•rWA wrrn.0 Y.1C: - APPLICATION FOR SANITATION PEt'.q[T 7S / (Compfsts In Triplicate) Permit No.This Penult Expires 1 Year From Dals Issued Date Issued 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/L ON F/ t A . ,.. . ... ......................CENSUS TRACT --...... ................ Owner's Name ` .. ... ...................... {lf 5....... . 1.JieY.. /.✓.Lc. ................ .. ................ ......Phone ..... . Address �j. .-. ttc/o1 ... . ..... . l�9/ .,.�;.. _. r �. City . ..a��,� --. ....jg✓/- Contractor'sNome ......t7-- .4a. ...................... . . ............. ....License$ . ......... Phone .............................. installation will serve: Residence❑Apartment House❑ Commercial roller Court a Motel ❑Other ............................. ............ Number of living units:.. ......... Number of bedrooms ............Garbage Grinder ............ Lot Size Water Supply: Public System and name Private Character of soil to o depth of 3 feet: Sand o Silt❑ Clay ❑ Peat❑ SondyLoamj Clay 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 ............... Capacity __ .- -..... Type .._. -------------- Material.......-.............. No. Compartments ......................_P Distance to nearest: Well ......................... ..........Foundation ...... Prop. Line ......................'c LEACHING LINE O No. of Lines . ......__.._ . . .. Length of each line _.................. ...... Total Length ............................ C. 'D' Box ..._ _... Type Filter Material .... ...............Depth Filter Material . ......................................... Distance to nearest: Well Foundation _...................... Property Line ........................ SEEPAGE PIT ( J Depth Diameter ._............. Number Rock Filled Yes ❑ No ❑ (10 Water Table Depth ......- .. . .............................Rock Size ................................ to Distance to nearest: Well ........................................Foundation Prop. line ...................... REPAIR/ADDITION(Prey. Sanitation Permit# ........ ----.----........................_ Date ..................................) Septic Tank (Specify Requirements) _...................................................�9 .. ...-----•,-/-•----••-•-----................_../..-----..._................. Disposal Field cif Require s) •---- --- jY--•--- --�---f-- mat-lt-------- i.`Cf•i-1r----->---1-:�---------------_---... 9' T� c-. / _ ......._..... ...... . _. - (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be dons in accordance witis Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Homs 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 ct to Workm Compensa ion laws is/ alifornia." Signed . . ....... .... . .. Owner By . . ............ , _._ .. -. .- .. .. Title ._ _ __.................._._....._ ........ ..... (if other than owner) PARTMENT USE ONLY APPLICATION ACCEPTED BY ---... . . ...........-- ... .. . . .._........... .... DATE cJ - `l BUILDING PERMIT ISSUED __.... .. .. -- .. ....... . ......... ......................_.._ ..........DATE . ..._ .................................. ADDITIONALCOMMENTS .. _ .. .. ... ... ... . ........ - _......_......- -- -._.........._..... _.-- ... _............. _. _.. .. ...... ............. Final ins pection by: _.. . ..... ............... - _........__....... ........_...... ... - ........ . ...... . .. . _ . . . .-------................----..............----..........._.........Date .... ..—.1_-. ... ................... 13 2!, 1-6f1 N OAQUIN LOCAL HEALTH DISTRICT 8/71; 3M