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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Pe rrrsit No. .-.-••----- - - ....,_: . (Complete in Triplicate( .. .... Data Issued` ........ 7.. .................................. . This Permit Expires t Year from Dah Issued str A lication is hereby made to the San Joaquin Local Health District for a permit to con uct and install the work herein i deribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ...CENSUS TRACT ..................... JOB ADDRESS/LOCi'Tl --...... ,V6 7: � Owner's Name • -- •. ............:........:............ Phone .. . 1 `'�S • •- Address - -•--_.....City ... cr-.........., -----.....- -2.- ..d�. .._ G�-r6 Contractor's Name License .......... Phone Installation will serve: Residence KApartment House Commercial❑Trailer Court ❑ Motel ❑Other ...-•-.................... �.J` ��C Z , . Number of bedrooms I.—Garba a Grinder ....----•••- Lot Size ........ ............. Number of living units:.____...... , Water Supply: Public System and name ------------------------------• -.- ... s.._ .....Private❑ Character of soil to a depth of 3 feet: Sand t] Silt p Clay ❑ Pea ❑ Sandy Loam ❑ Clay Loam , Hardpan Adobe t] Pill Material ............If yes,type............... ............ ( on to wells, buildings, etc. must be placed on reverse aide.! Plot plan, showing size of lot, location of system in relati NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer Is ova lloble within 200 feet,( PACKAGE TREATMENT I I SEPTIC TANK 13 Size-........................ . Liquid Depth ......................:... .� Capacity .:----- Type •-••----...... . Material................•--... No. Compartments ---......_............ V .Foundation -- Prop. Line ......:............... eft Distance.to nearest: Well Foundation'.k Total Length --•. --•-•.._...... LEACHING LINE ( ] No. of Lines ..__-. Length of each line..................... g q V BoxType Filter Material ...Depth Filter Material ...............•.. ...........•..-- Distance to nearest: Well ........................ Foundation ........................ Property Rock Filled n Yes (] Na SEEPAGE PIT [ } Depth _. Diameter ................ Number ........................._.. Water Table Depth Rock Size .......................... 1n Distanceto nearest: Well ...__... .Foundation ---.. ........ Prop. Litre ....:.•................ Date ``-REPAIR/ADDITION(Prev. Sanitation Permit� .............^.....--- __..... Septic Tank (Specify Requirements) /.... _................................ ....... Disposal Field (Specify Requirements) -------•n• 7 --•--- .. •------- ................... .�.. ....--_--- . .. +� {Drexisting and re ired addition on AR eras s e I I hereby certify"that 1 have prepared this t+ppifecition and that the work will be done In accordance with San Joaquin County Ordinances, State Laws, and 'Rules:.and•Regulations of the San Joaquin Coca! Health:Dislrict. 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 b e s bje Workman's Compensation laws of California." f . Signed .r_. .�_ ±�2( t s_✓ .- _!!?®_+�[5. n!�-_._ Owner ----- xitle -- ,r " ..... (If other than owner( / t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ -----•-- v DATE . _• ._ 7-- BUILDING PERMIT ISSUED -------- •- DATE .... ADDITIONAL COMMENTS 4-'--_-.. ...._;-i ; - ...__. ------------- -- --- ------- ---•-------------------_....._.......-------•.•-----......_......_- __ -------------- __ ....................... - --- ........._ .. _-_.. � ..._.... Final Ins action b Date - Inspection y: ..__. -- - -- --------- ------ ,....._ .. EH 13 Zit 1.-68 Hev. qi S N JOAQUIN LOCA HEALTH DISTRICT 6/7li 3M