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FOR OFFICE USE: '��it c- �✓ -�'"' ' APPLICATION FOR SANITATION PERMIT :�.._s.... (}.�J'....................: Permit No. rr I`• lComplete In Triplicate) ......I... .. . .4. • Issued ................3 .. •� This Permit Expires t Year Prom Date issued Date Z6, Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein 1 described. This application is made'In com ante with County Ordinance No. 549 and existing Rules and Regulations: 1 JOB ADDRESS/LOCATEO __ ( .G� ..�......:.............................................CENSUS TRACT .... -•--- Owner's Name — ... i Address city---------------•---- - .....Ci . -_. ..... Contractor's Name ...- �:�e�.._ .= .1�_., r,.:..__....License > • . .... Phone -: ....................... Installation will serve: Residence CAportment House Commercial❑Trailer Court Motel ❑Other."7Z _.- ..�,__ i Number of living units------ .__. Number of bedrooms :.��__._-CCarbage Grinder ............ Lot5 .....�Q -� • ! --- Water Supply: Public System and name ---=----------------------------•--.__...-_.__..._....._............_......_... .� P-._.........._Priva#e� `��. Character of soil too depth of 3 feet: Sand o Silt 0 Clay ❑ Peat❑ Sandy Loam ClayLoamlj Hardpan 0 Adobe 0 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 sewe�is available within 200 feet,) ., . E PACKAGE TREATMENT [ ] SEPTIC TANK Size.. tv?_---.4-.Z _ Liquid Depth Capacity _12_0�%�O Type - .!I - :• --- No. Compartments it Distance.to,nearest: Well _..I b *........•............foundation ...1 d.�......... Prop. Line ....�_J._,..:..._.._. LEACHING LINE [ ] No. of lines ........................ Length of ach line...._ . .. } / �' ...��.........--- Total Length ---`-��--�-�------ ---- 'D' Box .-.-l:.---. Type Filter Material . _�s�_ .�epth filter Material ................... Distance to nearest: Well __----11®........ Foundation .._ __.........__...... � ............. � �' Property Line ......... . SEEPAGE PIT �..._�___ _.------ Rock Filled Yes ❑ No 0 [ j Depth -----... Diameter ----------=----- Number .-------.........._ I Water TableI ,Depth ----------- -••----•-• .........................Rock Size ------•-•... ............. Distance to nearest: Well ....."'.`.'* _ .Foundation Prop. hrte _ ----------••--...•---_... .----••••........._ ................. REPAIR/ADDITION(Prev. Sanitation Permit# i . Date Septic Tank (Specify Requirementsl..................... -��.---$ i ...... ...............................--------....... ......... .....-•----. Disposal Field (Specify Requirements) � I --_"' [ I --- ------------------------•---- --------------------------------------------------............... .. (Draw existing and required aEddition on reveese side) "` I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin r n County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heolth;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 subject Workman's Comp satlon law of California." .... Signed --- 1.< - *� -�.4.A Y By _____ _______________________ B .,. l ...- " Title IIf other than owner .�w......._.. ------- FOR DEPARTMENT USE NLY 1 APPLICATION ACCEPTED BY .................................... - ----- ----- �- -- .......DATE :�3L - --------•------------ BUILDING PERMIT ISSUED _.._.... l ------- DATE .... :... ADDITIONAL COMMENTS ---......-_................................. ---- ----------------- x ----------- • - ------------ -------------------------------------•--••-------------- ---------------•--...--- ••-----------.-.------- ---- FinaiInspection by: -------•--------------•------ ---•------•-------------- ------....._._.._-- --- . . -Date ... _ SAN --............ EE[ ]3 2h 1-68 Rev. > f JOAQUIN LOCAL HEALTH I 1S CT 874 3