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FOR OFFICE USE: APPLICATION FOR SANITATION PeuVa (Coempleth in Triplicate) Permit No, .-................._. ...... This Permit Expires i Year From Date Issued Date 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. 5A4 and existing Rules and Regulations: JOB ADDRESS/LOCATION ......_ ...._._...__. .. --___" .... _ .. f1------ G�...-AW4P(M iSVS TRACT Owner's NameC ( . .. 15( Y0 tY ,9%fV---------------- .....------ -• -------- -----------------------------------:........Phone .__25;? Address G' ST� - city --..../Jrccq................. Contractor's Name ....., �1.. �G/ ----_-----• License t!` _,��5_.��.. Phone Installation will serve: Residence of Apartment House 0 Commercial❑Trailer Court �] Motel ❑Other ............... Number of living units:..../....... Number of bedrooms -.\:5_ ...-.Garbage Grinder ............ Lot Size ?-- Water Supply: Public System and name .......................... ----------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay.0 Peat❑ Sandy Loom ❑ Clay Loam J Hardpan ❑ Adobe ❑ Fill Material ...........Af 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 TANK; ] Size...,j --K--�-`y---f--4................. Liquid Depth ----.a'�.e..........-•--- Capacity ...... Type AX, Material.............:.... No. Compartments ............ Distance to nearest: Well ..... ,�l�...•...--. Foundation ., �- -•-----_-_ Prop. Line LEACHING LINE ( ] No. of Lines _......3............. Length of each line....... ......... Total Length 'D' Sox ..-/ Type Filter Material .I�, 1 ..t�epth'Filter Material ......41-./r ......__..._ Distance to nearest: Well ...._6_.R ............ Foundation ._.1a.............. Property Line .1.e .r.____._-•---• SEEPAGE PIT [ ) Depth ._..................- . Diami�ter'.•......:....... "Nur►tber :................---_--::-`Rack Filled Yea ❑ No ❑ Water._Table Depth ..........................-------------. Rock.Size............................. Distance to nearest: Well ........................................Foundation .._.._._.... ....... Prop. Line ................... --- REPAIR/ADDITION(Prev. Sanitation Permit# ............................................. Date .................................. Septic Tank (Specify Requirements) ..............____.............. .............-............ ....................................----------•-------_- Disposal Field (Spedfy 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 Joagrriu loco Health District. Norm owner or licen- sed agents signature certifies the following: "t .certify that in the performance of the work for which this permit is issued, I shag not employ any porion in'such manner as to become su$ject Worlitnwn's Cam ensafion laws of California:' p Signed ....... �. ..:.._ --- Owner By ------I---- •-•-•---- Title ................................ (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - _= --: DA 7r� - ` ----- TE .... ---•---..:...... BUILDING PERMIT ISSUED ------------------------ -- -• ------------ - -------_- 4.;...---_-----:_.DATE ....................... ADDITIONAL COMMENTS-................-......-__-- - - a , ._.................... --- -- .............................................. ...... .--•---------------------.............. Final Inspection by:.......... .c - Da .SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H.13 24 1-'6Rev. 514 7/771 rt