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AOR OFFICE USE: -•---------•-•-�••-•-.--....- APPLICATION FOR SANITATION PERMIT ------ IC*mplete In Triplicate) Permit No. ...7 ...... __-_- ..................................................... This Permit Expires t Year From Date Issued Date Issued .................... 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 rr compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION `$lS.. t k /4�.CENSUS TRACT ...DAP............. Owner's Nome _.. Q 1�1.1� ....... ...................................:..... ..........Phone . r �JDs ........ Address ........_-- �`. :Z►'. city�'� �•��. Vii:......................... ................................ Contractor's Name _-- lR�f►sth• p... -----•-••......................License Phone ..... Installation will serve: Residence artment House Commercial OTrailer Court ❑ 1 Motel ❑Other-----•._..._..--•---------- ................ Number of living units------- Number of bedrooms Garbage Grinder . Lot Size Water Supply: Public System and name -•-•-• ---- - •.................................--•.................................................Private Character of soil to a depth of 3 feet: Sand 12 ilt❑ Clay ❑ Peat❑ Sandy Loam (:] Clay Loam ❑ Hardpan❑ Adobe❑ Pill 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 seeps pit permitted if public sewer is vailoble within 204 feet00 PACKAGE 0 PACKAGE TREATMENT [ ] SEPTIC TANK Size.... 1 . . / . ............. Liquid Depth .......................... U1 Capacity TYpe l t _-_ Material- r :.. No. Compartments rZ..... 'stance to nearest: Well _S.P" ..--•--•--...•__.Foundation ..Id-------------- Prop. Line _._................... %A LEACHING LINE ll No. of Lines -. ✓ e € �•---------------- Length of each line...... .-7�_-._._... Total Length ._..A.1.0..........___. 'D' Box ...... Type Filter MaterialW ®.Depth .Filter Material ........� .... ......................... Distan to nearest: Well ---..;?. .......... Foundation ..../®_........,.... Property Line ........................ SEEPAGE PIT [ 1 Depth ----.....4---------- Diameter ---------------- Number ........:................... Rock Filled Yes ❑ No 0+ Water Table Depth ...... .......................................Rock Size ................................ Distance to nearest: Well ........................................Foundation _-_..............._ Prop. Line ..---._....._........ - REPAIR/ADDITIONPrev. Sanitation Perm t ........ ...--••----•-----•----•---- Date ------------------- --- Septic Tank (Specify Requirements) ............................................................................ ....................................... ......... Disposal Field (Specify Requirements} -----------Z-/ -------------------------- ....................................... -------------------- ............... . ----------- - ----•-------•--1------------ --•-------•-- - ....................•-••................................................•......... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heaith:Dlstrici. 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 manor as to become subject to Workman'smpensati n la of California." CJ Signed ---- a Jr � /'�/1 , - - ..... �f�... Owner BY ---------•----- .---------- -- •- -• -------- -•-••------- Xit�............ ... (if other than owner) FOR DEPARTM NT USE ONLY APPLICATION ACCEPTED BY ........ •�L � ---- -------------••--•--. DATE .../4,'.5-L".?.J�...-...-.: BUILDING PERMIT ISSUED ----------------------------.-------------•---------------------------------- -------DATE -...-------•-----.........---•--------..-_. ADDITIONALCOMMENTS ----- --.-• • --------------------------------------------------•-------.....---------------.....---------......------...........--=-------.................... ------•-------- ----------- --------------------•----------------------------------•-••---•----....._._...-_-...----------...-.....-...-..--.... ..--------•--------------------...---- -----. .. -. .----• .-.. �,/ InaInspection by- ----- . p ------------- ••.......---------•....----------•--------------Date .S. .x ..--.....--...-..----• IH 13 2a 1-68. V• SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M