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FOR 0,FICE USE: API�ATION FOR SANITATION PERMIT � .6.6D ..r.---- --:--::-i-- Permit No. .---.. .- . . --------------- - (Complete in Triplicate) __........ This Permit Expires 1 Year From Date Issued Date Issued ... Al. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein c'-scribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JtsB ADDRESS/LOCATION--'�- ------ -/--- p-`' .Y�4,. ..,_-------------------- ---.....---..CENSUS TRACT ------------------..... Owner's Name..... < c .� .�^ 7 n xc�_� e Phone _ Fdress -...s'i---t>. .,z+ .Y-e.__.1. . �13."J.-.�-------r- .----_ _._...--- ... City ... ...................... Contrattor's Name -----�"�A.:r:.As,./..� t .��.a G-t-'-`-=-L A)'-L-=--------.License # �. ._.Flt'.ate. Phone .............................. li tallation will serve: Residence QApartment House❑ Commercial ❑Trailer Court Motel ❑Other Number of living units:-_.. ----- Number of bedrooms ------------ Grinder -------- Lot Size ._ V der Supply: Public System and name ....----------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand❑ S' E] E] E] E] E]t Clay Peat Sandy Loam Clay Loam Hardpan Adobe ❑ Fill Material ... ..... If yes,type ------_.._...__.._._._ IP�ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse si, V-W INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) P`;KAGE TREATMENT [ ] SEPTIC TANK ] Size.. .._.._.._._.__ _.._.- Liquid Depth ------ ............... Capacity --- ------ - Type ---------------- -- Material--------------- ---- No. Compartments .---------------- ACHING Distance to nearest: Well ------..__-.__......__._........Foundation ------.__.___.._.. Prop. Line .___..------_---- LtACHING 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 ..._......__--------- V-AIR/ADDITION (Prev. Sanitation Permit# ------------------------------- --..-...---- Date ----------------------------------11 _eptic Tank (Specify Requirements) ..._-------------------------------------------------- -------------------------................. Disposal Field (Specify Requirements) ___________________________ _ _ _ ----- _ __ _ • _....---------------- --- ---------------- -- - - -------- '----- ----ter-. -- -- - - -X 4-S f -------------- -- --_...--------- ------------ (Draw existing and required addition on reverse side) i �reby certify that I have prepared this application and that the work will be done in accordance with San Joaquin C minty 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 entity that in the performance of the work for which this permit is issued, I shall not employ any person in such manner oo become subject to Workman's Compensation laws of California." r. Signed Byr --- (If other than owner) ene lit C:.:.Ftl.. :%�-4"c.,Lr. .------..._.._------------�- 4 Q ` FOR DEPARTMENT USE ONLY Al 'LICATION ACCEPTED BY - - ----- -- -- ----- -- - -------------------- ----------. ------- DATE BDING PERMIT ISSUED -----.._--------------- ------------------------------f ----------------------------------DATE ...............-........._...------------- ADDITIONAL COMMENTS ------ -- ----------- ------ - - .......----... ..... - ..... - ...._.... -- .... ..........................._........_... ....._...._.... -- ......................... - - - -- ----------------- ------- ------ ---....-------------------------------... kk� Final Inspection by: ------ -` -- .... --- - - - Date -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M