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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. .................... .. ..... .. . .. . . _. This Per •►Expires 1 Year From Date Issued Date Issued m Application is hereby mode to the Son 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. 519 and existing Rules and Regulationst : ` .�.1JOB ADDRESS/LOCATION . ....... CENSUS TRACTACT ......................... Owner's Nome 5r-1// // . _..� ..� .................................. one .................................... Address f 7`/'/l. 4YLc4-"ru C.I........ . . ..... ...........city Cis� ..... . . ....... ! Contractor's Name ' ..doys:........._..._.License �S�'$.�.�... Phone ,$'?L-. {� • Installation will serve: Residence Apartment Houseo Commercial [7jTraller Court ❑ Motel ❑Other I . . ...._............... / u Number of living units: Number of bedrooms ........Garbage Grinder Lot Size .Ifs r. •-L.•%j••--�•••••• Water Supply: Public System and name . ..............._ ........ . ........ .................................................Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpor.❑ Adobe ❑ Fill Material If y3s,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 ( 1 SEPTIC TANK O Size . ...... liquid Depth .... ....................,-.f Capacity Type Material No. Compartments ......................9 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: We'I _.. Foundation __ ... Property Line ... .................... SEEPAGE PIT [ J Depth Diameter .. Number Rock Filled Yes ❑ No Q Wcter Table Depth __ .. ............Rock Size ..._ ...... Distance to nearest: Well _. .........Foundation .. Prop. Line . .. ................. REPAIR/ADDITION(Prev. Sanitation Permit# Date . ................................ ) Septic Tank (Specify Requirements) .... ... . . .... ...... ..... . .. ............................... ...... ....... .............. Disposal Field (Specify Requirements) - 7,4.�.= ..... "r'„' ."r'..... �'. ir�o./v�'.. .._ ... ..... .. . ... ..... _ .... . ..... ......... ... ....... ..... (Draw :xisting 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 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 stich manner as to become subiect to Workman's Compensation laws of California." Signed _ Owner �� J By �L�it �v - / '�� TitleLGtYJn� (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE BUILDING PERMIT ISSUED DATE - ADDITIONAL COMMENy� r 1176 - h,,,,4" Rt-Al/A.. .. . ........ . ...... ............- _.............. .. ��Final Inspection by: Date : 9/l •. --•....... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 13 24 1•'68 Rev. SM 7/72 3 :i