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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT lComplete In Triplicate)" Date-Issued 5 - 7_�) This Permit Expires 1 Year From 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 ismade in compliance with County Ordinance No. 549 and existing Rules and Regulations: y 7 1 . :... JOB ADDRESS/LOCATION .../0,A_0_..&._... ..e�,....:. �'.T. .�.Q.G?.-----�1.�.....:..._CENSUS TRACT ......... ........... Owner's Name ... .fie.... .. ...............•------....: .__ f ....Phone _..... ......... Address I� .Q( .._ . ...... _.. .................. Ci .��Q. Contractor's Name ................4........License #o�: i7 ... Phone Installation will serve: esidence eApartment House 0 Commercial oTraller Court 0 - Motel ❑Other Number of living units:...--------- Number of bedrooms 1 Garbage Grinder ............ Lot Size ' Water Supply: Public System and name .............................................-:.........._--..................................................Private Character of soil to a depth of 3 feet: Sand t Silt a Clayo Peat Q Sandy Loam C) Clay-Loam"o Hardpan Q Adobe ill 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 I Size_ ................ .........•-------.....,..-.... Liquid Depth .----------.. .......,:..._ Capacity .. Material...................... No. Compartments .............. Distance.to nearest: Well .....................................Foundation ..__.. ....... Prop. Line........: ..:., LEACHING LINENo. of Lines ..................._-_ -- E lLength of each line............................ Total Length ........................ 'D' Box ............ Type Filter Material ..........-•.........Depth Filter Material ................................:.:......... Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT E ! Depth ......•.......------ Diameter ............ Number ............•................ Rack Filled Yea [] No (] In 1 Water Table Depth .. ---------•-•--•.............•-----•----.._......Rack Size ................................ Distance to nearest: Well --------------..........................Foundation .........-......... Prop. Line...................... :-_ REPAIR/ADDITION(Prev. Sanitation PermitS � ------------------------•--•-----••---....__ Bate -----•-•......•--•............ ._..) Septic Tank (Specify Requirements). ---- ------------------ ---- .... .................................... ••-- .. _..,:....._............. jI . f Disposal Field )Specify Requiremen ._. _ :: '` G --------------- ----- jDraw existing and required addition on reverse side( 1 -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 Sam Joaquin Local Health"_District. Home owner or liven- t sed agents signature certifies the following: "I certify)hat 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 ..... .. .!LC? . - ------•--------- Title --- .. . :.,. (if other than owner' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- -•--------------------------•- -----. DATE ..:5.. .a.7 BUILDINGPERMIT ISSUED ------ ----------------------- ------------------•-- ------------ •-------.......DATE ........................................... ADDITIONAL COMMENTS --------------•-- ....................... -••---------------............ .. . ................................................. --- --- •- ---=--- --------•- --- ...- ----------------------••---- - Final Inspection by = .".:Date -- --- - - . .. � .. EH 13 2b 1-68 1?,--V• 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M • i