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FOR OFFICE USE: 0,Co-,<;ZIV-2C Z rt APPLICATION FOR SANITATION PERMIT , ...................................................... (Complete In Triplicate) Permit No. . �..r.4.D.., « Date Issued .lQ............. -.---•..... ........................................_-- This Permit Expires t Year From Dale 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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ._.L.gla..$.. .,.. ..1...6P.R .. . �.. Q...� ........CENSUS TRACT .......................... Owner's Name .............................................................Phoney. �-9..:� .......... Address 4a � � G �.... Contractor's Name .....License +# ........................ Phone ...................... Y Installation will serve: Res idence WAportment House f] Commercial❑Trailer Court E Motel ❑Other --•......................................... Number of living units:............ Number of bedrooms -3......Garbage Grinder ............ Lot Size ..................................... Water Supply: Public System and name ......................................_.....................................................Privatex Character of soil to a depth of 3 feet: Sand'❑ Silt❑ flay ❑ Peat❑ Sandy Loam ❑ Clay Loam v Hardpan Adobe ❑ Fill Materlal ............ 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: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) , PACKAGE TREATMENTSEPTIC TANK ] Size....... ..R4..�....... [ l � ..................... Liquid Depth ..y..y...---•---..... Capacity j!�-.°7....... Type/3n,- Material... 'r No. Compartments ._. .............. Distance to nearest: Well 1,5.0..........................Foundation s ..... Prop. Line ` i 1J LEACHING LINE [ ) No. of Lines ....�--------------- Length of each line...q0_................... Total Length .l AV....._... _......00 'D' Box ............ Type Filter Material ....................Depth .Filter Material ............................................ Distance to nearest: Well ............ Foundation -----f ....... Property Line ........................ . SEEPAGE PIT ( ] Depth __ f"....... Diameter 0........... Number ..._..ti.�................... Rock Filled Yes X No Q1"' Water Table Depth ................................................Rock Size ............. "• --............ 6 � N a Distance to nearest: Well .45.6.............................. ---,1 --L Prop. Line -----•-•-----•--•-•--• Date ........... 4- REPAIR/ADDITION(Prev. Sanitation Permit�` ............------------•--............_ .-- -------•------------• 1 VIV SepticTank (Specify Requirements) ............ ................. ••---•.................................•----"•-............................. ................•-•-••-"--.... Disposal Field (Specify Requirements) "-•----------------------------------------•------------..._..---------...-----------------•----------------I.........."-••-...--' -------------- ---- --------•-•"---------------------------------------------------------------- •................. ------------- ------------------------------- --------------------------------------•---__.._.....--..............---•-............_. (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 focal 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 be subject to Workman's Compensation laws of California." Signed ------ Owner BY . �.� -- -� 4.. ........-- -------•- - Title ..- (If o#her than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ---------------- --------------------- DATE .... BUILDING PERMIT ISSUED --- D E . .-............ ...................." ADDITIONAL COMMENTS /Q�!T�S_.cS� �t�.__ - sco?4st ... . r..-. -.-.-.:- _ ..-•------ -- ------------- --"•"" in. .. - -- -- -- - ............... .......----------------------- . . .. --- . ---- --------- - - -- -- ................•----"...._---.-.-.-_...... Finalinspection by ........................••-•--•---------•------....---....------.._.............._.-_...................Date ...I EH 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/ 4 3M