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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit Na. �� b.......- 4 (Complete in Triplicate) .......... ............................................ �y *'� Date Issued .7-`. y...... I ................. This Permit Expires 1 Year.From 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 modgIlin�complianc with County Ordinance No. 549 and existing Rules and Regulations: ••L ////77Lr% _ JOB ADDRESS/LOCATiON .. S' __ ?!�' ;/ r^: _ _./Ll�d__. �..Q401 t-JCENSUS TRACT ...:..........:........... Owner's Name .... . W. � - , _ . - .................................... ----- � � - -•-••----------•-------- ..Phone _ Address ......�1 XO •'�---- 1?� ��A� fe. , fl_� ...... City ..5''�z �e_'T....__.•........----•---------•.............. Contractor's Name -----------•-•-------------•---- ------License # ........ ------.......Phone ....... •----•- ..... Installation will serve: Residence ❑Apartment House❑ Commercial;❑Trailer Gaf I Motel ❑ Other Xe_.11-/ 0e1W._Xrkv__� Number of livingunits:_.. Number of bedrooms _._;?-..-.Garbage Grinder ....._. ! -- ljoe._ lot Size ,g�_�4�9 ,t°l'..-•---==--••---- Water Supply.; Public System and name .........................................._.._...----•----.._..._...-------•------------•--------------------._PrivateJ9 > Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 Hardpan ❑ Adobe I@ 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 pit permitted if public sewer is available within 200 feet,) I PACKAGE TREATMENT [ ) SEPTIC TANK 5ixe ,,i� !•- "4�..•....................... Liquid Depths ................. Capacity /_�ea..... Type MaterialiCA$&:._..... No. Compartments ..�............. . ) Distance to'nearest: Well ----- .. t ....................P..................Foundation .,l e___.,._...... Prop. Line ..fp�7........_. LEACHING LINE A No. of Lines ------t ............ Length of each line----r __ Total Length 7� i 4 f 'D' Box &,$ __ Type Filter AActeriai•A &4 .Depth-Filter Materia! ,. Distance to nearest: Well 10..__....._..r. Foundation _ +i ._.__......_ Property;Line:,AW.:::_•::..... SEEPAGE PIr Depth o:-v0%7...... Diameter- ..---:Number __:_._ -................ Rock Filled" ' Yes No Water Table Depth 49K4 � .. __---k_-"'._ _-.Rock Size/ ✓�� f ,...J...f... Distance to nearest: Well ._.;�_aeg_______________________Foundatioh .-&......_..... Prop. Line _ ..... REPAIR/ADDITION(Prey.-Sanitation Permit# Date •a 4 _�. ...._...__.. Septic Tank (Specify Requirements) -- E + ~...............................•--•---•-----.--_-----.-------•----•--....... ........1.........................•-------- .:..... Disposal Field (Specify Requirements),.......#____- _ _ t ............................................... ------•--- -------•-• ----------------------•-.--------- -••--••----•. ----= --------------- --------I.........:.............. ��t�.._.l�_�._ --ice SSS%' (Draw existing and required addition on reverse side) I hereby certify that I have prepares!"this application and that the worlk will be.done in accordance with Son' 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 no ploy any person in itch manner as to become subject to Workman's Compensation laws of California." j Signed . .......... ....... _ _. Owner f � ' BY : . Title ......::............ # e (if o7h/f khanowned-:* - i FOR DEPARTMENT-USE ONLY APPLICATION ACCEPTED BY ........ .. ..............•-•-............_._.....•--........._............. DATlw ...._..... .. .. � '....... BUILDINGPERMIT ISSUED ..--• ......................................:.....................................•.......DATE .-•----------•.. .......................... ------------- ADDITIONAL COMMENTS -----------•-- .............................................. . ... .................... .............. Final Inspection by: .._•.... ....Date _... .. ._ZS _. _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1 E. H. 13 24 1-'68 Rev. 5M A 7/723114