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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete In Triplicate) Permit No. ......... ... ....... ..................................... ... .... /1 ) C ......................................•---........ :;�1.�\ Date IssuedThis Permit Expires f Year from DatelssuIssued ........-...:..... 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/LOC ION At�o! _....,CENSUS TRACT1y4-�x,�d...... / Owner's Name 0.4?Pit! . .. Jr�` , .................. ......................... ....... phone . Address _ / _... ..... City ity Contractor's Name[� - — ...zn'y,—!- .L .................License tit s: Phone 3 ��`. t c: Installation will serve: Residence EkApartment House Commercial❑Traller Court Motel ❑Other............................................ Number of living units:............ Number of bedrooms ........Garbage Grinder ............ Lot Size .. iQGe2 ,cr.................... Water Supply: Public System and name .......................................................... ..........Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam [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 Pa i 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: Well ........................ Foundation ... .................. Property Line ........................ rn SEEPAGE PiT ( ) Depth Diameter ................ Number ............................ Rock Filled Yes ❑ No ❑ Water Table Depth --------•.......................................Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ............. ........... Date ..................................) Septic Tank (Specify Requirements) ............... ................................................ -................. 0 Dis osol Field (Specify Re uirements) .....3-o_..........T '! �/l.Y ...._^...1............. �f /yf-fid..._....._.-�_.......`.5.a�.......... ...... .......... •- 1 ...GcJ�.�iF ............ .s.� t? o......... y...... ............................. ---------- ............---..........-............................................................................................ (Draw existing and required addition on reverse side) 1 hereby certify that 1 have prepared this application and that the work will be done in accordance wltk 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: "1 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 subject to Workman's Compensation laws of California." Signed -- ........ ------ ------- Owner BY .oth---•e •-------------- •---- ......................... Title ..��CU�[G-...... Ilf r than owner► FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .....C _......`-------------- DATE �?-�.... . � ..... .,.. tNG PERMIT ISSUED . .............. . -- .. .._......... ....... DATE . ._._ .............. ADDITIONAL COMMENTS ......--•-•..........................••-•-•--- ......................................................................................................... ...... .................................................. •...............................•-•-• -•---••...........................•-•---...... .......... .............. .......... . .................... -"---•-- ................................................. Final Inspection by:p ........ ... ... . ........ .. ...................................................... -- ..._............. ---•-••---..Dale�.... .. 3...._... ...� EH 13 2h 1-6f) Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M