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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete M Triplicate) Permit No. .........................................____..-.---.---. This Permit Expires ] Year From Date Issued Date issued .............7 6 Application is hereby made to the San Joaquiri 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: JOBADDRESS/LOCATION ...................-.................................................................-....................CENSUS TRACT .......................... Owner's Name ... -401"-8L--- -- . .--- - Q 1�` &............................................Phone .5- ..Q,4-. Address �t7��s" Q �7 �1�!j.OL1pRr.,/ ' ---- ---- ..................................City .!i .e�!�'1.I._�.............. . Contractor's Name __ � _�... `GG � r�r`C. ----------------License # IV.RQ..4..9.-- Phone Installation will serve: Residence 21 Apartment House❑ Commercial❑Trailer Court ❑ Motel ❑Other T. 3/Q......................... Number of living units: (0_-___ Number of bedrooms ..j=?----Garbage Grinder ...Q..... Lot Size .................. .............................. Water Supply: Public System and name -......•-•---------------....................................................................................Private Character of soil to a depth of 3 feet: Sand — Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ Hardpan Adobe 0 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,) 1l1 PACKAGE TREATMENT l• ] SEPTIC TANK I ] Size................................................ Liquid Depth ---------- ....... %0Capacity .....Ced.Q- Type&14457.. MaterialC"WO No. Compartments ai Distance. to nearest: Well . '�.........................Foundation ...ern............. Prop. Line ...................... \ NG LINE [ ] Noof Lines _._. _ _ - - ' LEACH( . - - ----------- length of each line..... �./.._........... Total length .... ........... 'D' Box -. ...... Type Filter Material ...1.2-----------Depth Filter Material ..Z.7r................................. a� Distance to nearest: Welt ...�Gw1 ......... Foundation -J...............•- Property Line ........................ io SEEPAGE PIT [ ] Depth -------------------- Diameter ................ Number --------................. --• Rock Filled Yes ❑ No IQ f I Water Table Depth --------------------------------- ......Rock Size ................................ 1 Distance to nearest: Well .......____............................foundation ----------.......... Prop. Line ....................... REPAIR/ADDITION(Prev. Sanitation Permit 0 ----------.................................. Date ._..- ............................ SepticTank (Specify Requirements) ................................................................ .............--...................................................:......... Disposal Field (Specify Requirementsl .-•--------------------------•------.......--•------------------.........--------------------•_....------•-••-•---._...--•----------- ------------------------------------------------ --------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 Son Joaquin Local Health,.District. Home owner or liten- 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 become subject to Workman's Compensation laws of California." Signed --- Owner By ---- ••-- -------------------------- Title _.fly . (If other than owner) FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- ---- DATE . -' - ?6 BUILDING PERMIT ISSUED -------------------------- ------- ------------------------- ..._.---------DATE ........................................... ADDITIONAL COMMENTS -------•------------------------- ----------- -------------------- ------------- --------------------------- --•-------- .------...------••-------------.. ----------- ........................... ----------------—1..................... -----------------------------------•--•............ . Final Inspection by: Date --.-/-- -2G...................... EH 13 2h 1-6$ lav• 5MSAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M 1