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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT S-ydq .............._..-.-......-......-.........-............ Permit No. . .._....1. ... ................................................... r ; (Complete in Triplicate) Date Issued ,/O- ....................... / ......................... t This Permit Expires 1 Year From Date Issued .�.......... POS- f{oa K/� i Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work heroin described.This.application is.made. in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA N .lZ.ki.. ._.H k� 1....` ..- b o 4� CENSUS TRACT ... ......... ........ Owner's Name�...... -!mac �Q-.._._ .._........_........ ..... :.. ...... .......Phone ......_ . _... Address .------4.2.el.�. : :._......_.Ci .. .. .. ..... .................... - ........__......._. Contractor's Name ....� trr. --. g--_ :._-,Lkense # � :.. Phone .............................. Installation will serve: Residence❑Apartmen use❑ Commercial(]Trailer Court 0 Motel C3 Other,. -4............... Number of living units:..... Number of bedrooms ............Garbage Grinder ............ Lot Size ........... ................. Water Supply: Public System and name ..----..........:..........-...._.......--------------......._...... ........................------Private Character of soil to a depth of 3 feet: Sand L1] Silt 0 Clay 0 Peat C] Sandy Loom ❑ Cloy Loam 0 Hardpan iJ Adobe❑ Fill Material _.......... If yes,type;.............1.----.__- (Plot pian, showing size of lot, location of. system in relation to wells, buildings, etc must be placed on reverse side.) I NEW INSTALLATION: (No septic rank or seepage pit permitted if public seweris available within 200 feet,) PACKAGE TREATMENT [ ]. SEPTICTANK{ ] Size—........_................................... Liquid Depth ........................ j[J Capacity :............ . Type - ................ Material...................... No. Compartments .................. yv!. Distance to nearest: Well ..........:..........Foundation .... ........... Prop. Line...._................. '. LEACHING LINE [ ] No. of Lines ........................ Length of each line..................... ..... Total Length ............................t" • 'D' Box ...L----- Type Filter Material ...:................Depth Filter Material Distance to•nearest: Well ....:.:..........::...... Foundation ........................ Property Line SEEPAGE PIT [ ) Depth ..._p............. Diameter .. ........ Number ..... ...................... Rock Filled Yes [3 No . Water Table Depth ................................................Rock Size ........................ ....... Distance,to nearest: Well ........................................Foundation ............_....... Prop. Line _.......-..... ....__ REPAIR/ADDITION(Prev, Sanitation Permit*# ....................................n...;.. Date ..................................I ic Tank t �....X�ecRS.v-iremen1 ...... _ . - .............. ........ _.... ... - ............... Disposal Field (Specify Requirements) .. . . r .. .. C ----.._...................... t / (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 Son Joaquin County Ordinances, State laws, and Rules and Regulations of the Son Joaquin Local Health District.Home owner or licen- sed agents signature certifies the following: _ "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mannir as to become subject to We an's Compensation lows of California." ' Signed .......................... ......... ._. - Owner .. . ..... . ....................... r 8y .........- - . ....... .:.. .. .......... .....:.. Title .. .-........ .....45 !!'?<:........ ......... ...... _ (if other than owner) ; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY......._.�.. rl..........- ......---......--. DATE ........-�..1�._.�3- .......... BUILDING PERMIT ISSUED.. . .. . ..-- =`--- -... ............. ................................: ...... . ........ ..:..DATE ....._.......:...._................ ...... ADDITIONAL COMMENTS. . ............ ............ -----.....-_•-••------- - .........,._ .............--..........._...-.......... .......... ........_.......- ...... .. ......... .. + Final inspection b ,,��.---...__............................._........................................._ .._ . ......q .. .....�............. P Y� .........................4.... Dote .......1 --/.,1�.�.f................... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 241•'68 Rev. 5M T_ _ - 7179 'i M