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POR OFFICE USE: APPLICATION FOR SANITATION PERMIT .............. 'va.l �--_.................. 7.1 - S6 IComplefe.in TAplicate� Permit No. .7 Dote Issued ..C7-::A2-.76 ...........................................:............... . This Permit Expires I Year From Date Issued i Application is hereby made to the San Joaquin Local Health District for o permit to construct and install the work herein f described. This application is made in compliance 'th County Ordinance No. 5:49 and existing Rules and Regulations: JOB ADDRESS/LOCATI N .-.4 V�....�. ... ...CENSUS TRACT Owner's Name . ..... .. � Phone .... ........... ........--............... . Address ..- city Contractor's Name ---• . ..... . �21 Lice nse # ..627...3Y... ....... Phone ._............................ Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court [3 Motel ❑Other ......................................... Number of living units ... Number of bedrooms ..�'�........Garbage Grinder Lot Size ............................................%N! Water Supply. Public System and name ... .•.Private Character of soil to a depth of 3 feet: Sand CJ #❑ Clay ❑ Peat❑ Sandy Loam Q Clay Loam ❑ Hardpan Ef Adobe fl 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 seep a pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK f Size. .---- � ............ Liquid Depth Capacity tS�`Qd•------- Type - Na. Compartments ments ...� ........ . " V --_ Distance.to nearest: Well _____..__.�� JI .........Foundation .... PA _ Prop. Line __ ....... LEACHING LINE No. of lines --- ------------- g Length of each fine...__ .-_�._ Tota! Length j 'D' Sox el 1 ..... ..... Type Filter Material .....��.....Depth Filter Material .../. .. .............................. Distance to nearest: Well ....��..._ Foundation .---A))' Property Line . . ..... ....... SEEPAGE PIT ( Depth e;'_Z.Hr�DIameter ___. �� Number .._-__.._ .............. Rock Filled Yes No I] Water Table Depth .........L.IA-0Z/4 .----•------------- Rock Size Distance to nearest: Well ....-.•-- foundation ._.1 Prop. Line ...� r �.... REPAIR/ADDITION(Prev. Sanitation Perm It# ...................... ..................... Date ---•--....... .................... Septic Tank (Specify Requirements)........................................... _.._ ....1........................................................... •............................ J DisposalField (Specify Requirements) ------------•........................................... ----------------------------------------------------- ....... -------- Draw existin and re wired add it on r --•.... -• .. ........................ ( g q eve rse side] I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Ryles and Regulations of the San .Joaquin Local Health,District. Ham* 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 -------------- -r�� --" ' '-e --.... Jitle _. �-fr'zvv --------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- - . ............ DATE ..� -Z... --------- BUILDINGPERMIT ISSUED -------------------------•. . • . ....................................---------------------------------DATE --------------- -----.. .......... ADDITIONAL COMMENTS ----- • •------- - ----------•----•------.._......_.. ---------------------------------------•---•-•-•------------ -------------------------- --------------------------------------------- --•------- ........................_--------------------- ------------------------ ----- ------------------------ - -----------------------...................................----------------------- _... ina Inspection by: ......... ...... -----------•--- ----.........•----...----••--- . ..-._---Date ..... ...-......... EH 13 2h 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M