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FOR OFFICE USE: A�� 1APPCATION FOR SANITATION PERMIT ..........I........................ 9.. Permit No (Complete in Triplicate) .......................... This Permit Expires 1 Year From Date Issued Date Issued��.._�...� Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described TThi§ a plication is ade in am 11 nce Cour2y Or in an exi ing Rules and Regulations: JOB ADDRESS/LOCA T N ..... _. - . . ...... ...............CENSUS TRACT ........ ............ Owner's Name --•---------•. --:-.. Phone 1.. J"� n /....... ... Address .........AV-3__ ��1 '!. City ... Contractor's Nome .............. .................. ..... .. ... f!L�f�......................License #. sy _.3 _. Phone ----•--•---................... Installation will serve: Residence ❑ Apartment HouseKornmerclolOTrallerCouet 0 o,Motel C]Other4 .1rt �cy�t G. . . Number of living units:...---...... Num er of bedrooms ............Garbage Grinder ............ Lot Size ........ .............. Water• Sup 1 : Public System and name........................... ........:.... ............... ................__......._.... ,__• Private.[] Character of soil to a depth of 3 feet: sand-O Silt❑ Clay ❑ " Peat❑ Sandy Loam�, Clay Loam` Hardpan ❑ Adobe 0 Fill Material ............ If yes, type ............................ {Plot pian, showing size of lot, location of. system in relation-to, wells;•build ings;.�etc-..must be placed on reverse side. NEW INSTAL LATZ'--v�.(No septic tank,or<seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ` a REATMENT [ ] SEPTIC'-TANK_ Sixe.... �.7� / L------- Liquid Depth ..._.�ct�. ........... - k , ....._ Material,.-}' Capacity r � Type , ... No. Compartments .... ........ Distance to ineorest-Well.. - •..........................Foundation .....r.Q..:�-:..... Prop. Line _ .. ..__...... 1 LEACHING LINE No. of Lines ........� Cength of each line------- Total Length ... r. ............. D' Box _... ...... T iltel hAaterial Depth Filter Material _ --r- i .:.......................:.:... Yfa p i r t r I t. Distance to-nearest: Well ....I...... . ...=Foundation-�-._10::f—�—'Property Line ............. SEEPAGE PIT [ l Depth ____________________ tb�ameter __________..____ Number __------•---..__ Rock Filled Yes [] No Water Table Depth ...... ...........-14. .......Rock Size -------------------------------- - Distance to nearest: Well ............................... ......Foundation ._...._---------._[ Prop. Line ----_--------- REPAIR/ADDITION(Prev. Sanitation Permit# .....:............... Date ............................... Septic Tank (Specify Requirements) --------- ----------------------------- �........--.... '�-------.:_... Disposal Field (Specify Requirements) -•- _..............................,..---.....-•-------.•................•------------------ ..................... _ _-- . --. -- _ A I r. ---.-._------------------------------------------------------------------ -----------------------------------------------------------------------..._._..--------....._..I..---.............. (DraW existing and required addition on reverse side) I 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: , C_ — . . I "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." t Signed .....� ' Owner By :................. ..... ..... n (If than ow ....... , t FOR DEPARTMENT USE ONLY �. Y r. t APPLICATION ACCEPTED:ABY .. .._. . ----------•---•----•--------- -------•----•-- n :- �.cl DATE ....Io- -'1 y.._ BUILDING PERMIT ISSUED`. -- •.................... • •.DAT(: ........--.. ADDITIONAL COMMENTS .. ...!t7 ................. .. ... .......---.....-••--................._..._............-•---•--•-•-•--•-•- . -- . .........................................t...-- -• ... - . - Final Inspection by:�� -----•---------••-----••..................•--•-•---.................•---...-----•---....._........Date ..:._....b. ._._SAN.JOAQUIN LOCAL HEALTH DISTRICT _ ,• l E. H.13 241-'68 Rev. 5M 7/72314