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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ..... ..............................I..... Permit No. V_A (Complete In Triplicate) gg ..7... ............................................. This#'ermit Expires 1 Year From Date Issued Date Issued��l.: j Application is hereby-made to the San Joaquin local Health District for a per to construct and install the work herein a described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations- AXAVUAW.:..... .. ..... ...... . .. ......•......CENSUS TRACT ....................._.... - - Owner's Name ......... V1v11 ........ .1. ,t �Jh, '.. Ph.................•---..,..................................... one .G 1' •-• �C� - Address .... . :.. .......fes / ... 1� .......................................... City . /,:, Q -..............---•-• ........................... _ - f Contractor's Name .....�� ,�` �� ' .. �C__: 1..........License # / , , :.. Phone Installation will serve. Residence WApartment House❑ Commercial [:)Trailer Court Motel b Other........................................... : _ Number of living units.._..f..... Number of bedrooms ...3.....Garbage Grinder A/P.-.. Lot Size .� - f7••�-'• •.... r Water Supply: Public System and name .--•-•--•................. .........................-..........................................................Private Character of soil to a depth of 3 feet: Sands[ -Silt❑ Clay ❑ Peat❑ Sandy loam ❑ Clay loam ❑ 4 Hardpan ❑ Adobe❑ Fill Moterial ............ If yes,type ............................ i (Plot plan, showing size of lot, location of system in relation to, wells, buildings, etc. must be placed- an reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) L PACKAGE TREATMENT [ ] SEPTIC TANK Size..� a '. .:..:.......... Liquid Depth ............... t Capacity��X.4,2.. Typ Material i No. Compartments .----..... Distarice to nearest: Well .......................Foundation . .......-___-• Prop. line _.6�................C4 LEACHING LINE No. of lines _. . .._.. _. -..... Length of each line._ �................ Total Length .�-��._�.......... �' _ . 'D' Box .� Type Filter Material j-Q.L'��....Depth Filter Material .,� ..................................... Distance to nearest: Well . ©........ Foundation ........................ Property Line ._3_ ............9 SEEPAGE PIT [ ) Depth ...................:. .Diameter . Number ... (tock Filled Yes ❑ No C3 Water Table Depth ---...-•--......--•........................•-...Rock Size ............................. Distance to nearest: Well ........................................Foundation ..................... Prop Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................. Date .................................. Septic Tank (Specify Requirements) .................4.......................................................... I Disposal Field (Specify Requirements) ................ :.. ...... - ..... ............ .:.:....- •--......?...:_..... ........ ...........................................................................:.•---------........--•••---------.........----------......•••--•-•••-•-----..._.....:........................................ (Draw ekisting 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 San Joaquin County Ordinances, State Laws, and Rules ±and Regulations of the San Joaquin Local HealtK 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 such manner as to become subiact to Workman's C mpensation laws of California." Signed ..................................•------•-- ........ .. .. --••--• --........... ...... Owner J . By ......................................... ==......... Title .....e1 Y. ......--...--........ (if other than er)� FOR 'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _. DATE - ...... ... ..... . .•. ... ................... ...--- ,. ... BUILDING PERMIT ISSUED ....:DATE ::w:...................................... ADDITIONAL COMMENTS ................ .......................................................... ..•.......................••_ .............._.............. •• ...._____.........__...............__..._._.........-...•--.....,....•E4. .. ...................... ........... ...... ..................... ..-. .. ... .. .i.~......... ....... Final Inspection by; ...:_. .:............................ .......Date ...... '._ SAN JOAQUIN LOCAL' HEALTH DISTRICT E H."1.3t241-'GB Rev. 5M m 7/72 3 M