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FOR OFFICE USE: Ji APPLICATION FOR SANITATION PERMIT Permit No. IComplete In Triplicate) 1 =...........................•---•---•----•-.... .. This Permit Expires I Year From Date Issued Dote Issued ............__..__.. Application is hereby made to the San Joaquin Local Health District for a per 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 .... !1/0 r�.0-_. .C�iw........!a. .............CENSUS TRACT .......................... Owner's Name .---.Kvh ...... . ....... ........I............................Phone ......................... .......... ................ ........................................... .... .. city .........-__. Contractor's Nome .......... ...License ................. .. Phone Installation will serve: Residence Q Apartment House Commercial OTraller Court D t _. _ . r -Mote(QOther ...................:........................ Number of living units....1... Number of bedrooms ..Garbage Grinder .......:.... lot Size Water Supply: Public System and name ......................................................Private 0 � r Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay p Peat p Sandy loam Q Clay loam ❑ � Hardpan❑ Adobe b Fill Material ............ 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 spit-permitted-if public sewer is available within 200 feet,) VJ PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size...._.......................................... Liquid Depth ................ ........ -Capacity ---- --------------- Type -•--••--••-............ Material...................... No. Compartments ...... ............... Distonce. to nearest: Well ...Foundation . Prop. Line LEACHING LINE [ ) No. of Lines . Length of each line............... .........__. Total Length, ............................. } j , 'D' Box Type Filter Material ...Depth .Filter Material .. Distance to nearest: Will Foundation Property Lina SEEPAGE PIT[ j Depth .............. ./Diameter ................ Number' ............................ Rock Filled' Yes ❑ No Q� J.. 5 Water Fable Depth ...... ....................................Rock Size i Distance to nearest Well .............. ...........:_......Foundation .. Prop. Line ' REPAIR/ADDITION(Prey. Sanitation Permit# ......:.:._...... - ..-'....... ate ........_.:_ } y Septic Tank (Specify Requirements) _.:: .._ - ' ..�..4..... lF.... des. Disposal Field (Specify Requirements) ------------- .......__......_... .............. ------------------------------------------------•..................... ......................................................-............................................................... .... - - - - - --- ----- ---- _ #Draw existing and required.addition on reverse side) I hereby certify that I have prepared .this-application-and-th at-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. Norse owner or Ilcen- zed 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 sub ct o an's CompQmation laws of California.., Signed . .. ... y--- - - -------------- ---- --------------------------------------- Owner By ............... ------ ................ Title (If other than owner) .42 R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..... -- ----............................. DATE -------------- BUILDING PERMIT ISSUED DATE 4 .....f....r ADDITIONAOMME ....TS z -------------- ----------- ------------ ------------- . ------------------------------------ . _ . . -- . ............ -------------- ------ --- - - - • .... ...----•.. .•------ _.......-- •---------•------- ---•--...--- Final Inspection --------..-•........................................................ . Date -. ..-... .. / . . ...........y: -- EH 13 24 1-68 ,,' Rev. 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/71i 3M