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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .............. ...__........-...: . .7....:.........: (Complete in Triplicates Permit Na • This Permit Expires 1 Year From Date Issued Date Issued ...7: 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: 1...!.'fir-•CGvG- , -0 /..-.� ,/,L......CENSUS TRACT .......................... JOB ADDRESS/LOCATION,5/9&.s P./4f- .//v..._. QZ iM ...._�� vS.. .�'.........._ : Phone .................................... Owner's Name ........_. Address . OGOd 1��1. So ✓. .� .................•................::...*City .. ?�e5!..X*............:_.:. . ............'�. Contractor's Name ...........Se,&............................License #l6i?:7e a.... Phone _`�-y4!_1.. Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court Motel ❑Other ............................................ k /d c5 Number of living units:.... ....... Number of bedrooms ............Garbage Grinder ............ lot Size ........._.r.............._................. ~ Water Supply: Public System and name ...... .....C*r........... ..............--...................................................Private ❑ Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam Z Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type............................ -- C7 (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,) 3 PACKAGE TREATMENTTANK-[SEPTICSize_. - r�'� 6") ........ [ � � .................................. Liquid Depth ....`1_�........... � l Capacity .1. ....... Type ..... Material ..... No. Compartments ................ Distance to nearest: Well .._................................Foundation .....!�-.......... Prop. Line ..-.3.5E........... O LEACHING LINE [ ] No. of Lines ........................ Length of each line............................ Total Length �4 '.X-2'.0"...... Fi` l-ey gcw 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................. �G7CI 5�/• �� Distance to nearest: Well ........................ Foundation ............ Property Line . � ...............: SEEPAGE PIT [ j Depth Diameter ................ Number ._..._... .................. Rock Filled .Yes ❑ No Q Water Table Depth ................................................Rock Size ................................ Distance to nearest: Well ........................................Foundation .. Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. SepticTank (Specify Requirements) .........................................................................................................._..,............................. DisposalField (Specify Requirements) ..--•--•---•-•...............••-----•---•---•--•-----------......----•------ .._....-...-•---.•..-..._..•......._......-............ ----------------------------- .......... •-------••-••--_....-----.-••-•-•-••-•••----•••----•-•--••••••...•-•--••--••---••••-•-.......•-•--••-•--•-•••-•••........-••-••-••••.....--••......_...----...... .......................... ........ . ............ ..................................-............................................................................................ (Draw existing 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 Health 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 to Workman's Compensation laws of California." Signed --- � Se's ......................... Owner Byi'1.G�7... . _. ::... :......--•-•-.......--•...•••.......... Title ........................................•-....... (If oii'tieerr�hi�a ....................... FOR EPA TMENT USE ONLY APPLICATION ACCEPTED BY ..... ........................ DAT .. ....^ .` . BUILDING PERMIT ISSUED ........................................................:..............DATE ................................ ADDITIONALCOMMENTS -•.............•--.•......---....................................._..............................:----•-•--.......................:....::..................... ................................................_............................,.................................................................................,.......................................... ................................. ...... ................................................................... ............. ....... Final Inspection by: ............. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 241-'68 7/72 3 M