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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------- - ------------------ in Triplicate) Permit No. e -------------- --------------------------------------- {CompleDate Issued --------------_------------------------- This permit Expires 1 Year From Date Issued 2-o g- 21f�0-l�a 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: ',2(n5`rs s�,. JOB ADDRESS%LOCATION --- KREO i---- ------t/X_l?JW1Q--------------------------------------------- ---CENSUS TRACT ------------ Owner's Name ��tIa-5,- -C_-6-�------------------------------------------------------------ -------Phone ------------- ---------------------- Address +4L�X-__6-7----------•------------------------------------------------- City ----1�A-t'-11--------------------------------------------------------- Contractor's Name ------ - C -------- - License # ---- ------ Phone ------------------------------ Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ',❑ Motel ❑Other ------------------------------------------ .Number of living units:---.1----- Number of bedrooms ---t5 .-.Garbage Grinder �-,___ Lot Size ------ --------------• Water Supply: Public System and name ----------------------•----------•----------------------------------------------------------- ----------------Private,F!] lr� Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat E] Sandy Loam ❑ Clay Loam E] Ha dpan ❑ Adobe Fill Materia! - 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 TAMC:[r1,11- Size--_---;20= CZa- ------------------ Liquid Depth -5--/-------- ----_.Capacity �Z006------- Type Sor------------- Material-CU21 --- No. Compartments ---OLL------------ Distance to ne11a��rest.. Well ------tL�----------------------Foundation -----_AP------_----- Prop. Line --_--0::__---... n LEACHING LINE [ ] No. of Lines AM------ ------ Length of each line__ -+-5�°- ------ Total Length --------------•- -- 'D' Box ... -__ Type Filter Material -- - 10L---Depth Filter Material -----i5_-- ------ _------- ----------- f Distance to nearest: Well ........... Foundation ---t00--__--------- Property Line. ---------------_--..-... C SEEPAGE PIT [ ) Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth ------------------------------------------------Rock Size -------------------------.------ Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------------- ....... 4 REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --_--------_-_.._--_-__---....___-� Septic Tank (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." Signed9------- -- ------------------ -- --- - ------------------------------- Owner By ---- ----------------------- ----------- ----------------------- ------ Title ------------ (if other than owner) FOR DEPARTME USE OLY APPLICATION ACCEPTED BY ---------- P�9� DATE ---- ----------- ---- ATE BUILDING PERMIT ISSUED ----------------------------------------- ----- ---------- = -----DATE ----------------------------------------.. ADDITIONALCOMMENTS ----------------------- - ------------ -- ----------------------------------------- --------------------- ------------------------------------------- ` ----------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ' --------------------------------------------------------------------------------------------------t---------------------------------- ----------------------------------------------- ------------- --------------- FinalInspection by-- ---------------------------------------------------------•------------------------------ -- ' Date --------------r------ ---" --- - --------- SAN JOAQUIN LOCAL HEALTH DI RIOT E. H. 9 1-'68 Rev. 5M