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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT s I.. (Complete In Triplicate) Permit No. . Date Issued Z'0'7 : + _.......____,_.- ... This Permit Expires 1 Year From Dot*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. 9 and existing Rules and Regulations: JOB ADDRESS/LOCATION ...... q�., /� �' / / �.. Iva .--_�•......1/C .1..1.7`x... -_tel ....CENSUS TRACT .................. Owner's Name .. �........�1.0_�L.S./�---- -- ol- .... . hone Address tet) ._...._ --•. -•- -------- ----•- ------ ... GES ... ..-•-- --• , Contractor's Name f P License # .. /5.1.��Phone . .. .. Installation will serve: Residence artment Housed Commercial ❑Trailer Court E) Motel ❑Other----•---.--- Number of living units ........... &ul mber of bedrooms Garbage Grinder.. Lot Size - -.......................... Water Supply: Public System and name .............. Private Character of soil to a depth of 3 feet: Sand 0 Silt Clay Peat Sandy Loam IJ Clay Loam ❑ Hardpan ❑ Adobe Fill Material . If yes,,type ............... ............ E (Plot plan, showing-size-�of•lot;IocationTof-system--in- lotion' to wells, buildings, ,etc. must be placed on reverse side.) NEW INSTALLATION: iNo septic,tank or seepage pit permitted if public sewer.is available within 200 feet,) O I PACKAGE TREATMENT ( ] SEPTIC TANK I ] Size................................................ Liquid Depth ..... ................. Capacity Type __ Material................ ..... No. Compartments +: " •i--•....................................Foundation ...................... Prop. Line ..........--- LEACHING LINE- - ----No:-of-Llnes- Length of each line.. . :. Distance. to nearest: Welt i { ----- - _......_.. Total Length D' Box Type' Filter Material .__:-- -- _...._-r__-•--.,�..-..Depth_F.ilter Materia! Distance to nearest: Well ___ _______________ Foundation .___...... ...... Property Line j SEEPAGE PIT � I ....................... PAGE PI,,. ( l Depth ... 1--------••---- Diameter ------------•--- Number �._..... ^+Rock Filled Yes ❑ No O° � Water Table Depth -------------------------------------------------Rock Size •--------• ................ Distance toi nearest: Well ..___-___ ---------------------- -------Foundation .__ ................ Prop. Line --- ...... REPAIR/ADDITION(Prev. Sanitation(Permit _ ......... ------------------'.-...-------- Date ....................... Septic Tank {Specify Requirements) ------ ------ ............. . / . .._._... . �,. ........ Disposal Field (Specify Requirements) „--•:-- _,r-•---••_ -- ..... "_•. p.7 -------------------------- _ v _____________ --------------------------------------- __"_"._.___.._....__._-.._-.____________...._____-___•,....__....__.___......_.__......_.__..____......_..... _ ......_.___...... .(Draw existing and required addition ori reverse side) I hereby certify that 1 have prepaitd this application and that the wark~vv ll be done In accordance with.San Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health,,01strict. Horne 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 not employ any person lin such manner as to become subject to Workman's Compensation laws of California." # Signed -------------•------- ------------- ----- Owner BY - ----------- - ------- -- Title ----- -• --------- ------------------------------ (I of han owner) FOR DEPART NT USE ONLY k APPLICATION ACCEPTED BY __ _--.- -. " •"-- DATE BUILDING PERMIT ISSUED --•-- L �� ._.: ..-____---- ••- ---- - -------DATE --------------------------- ADDITIONAL COMMENTS ..----- ' I f -----••----------------•... -'---------------•--•--------._... Final Inspection by: .._._--_-••- Date :.D, EI•I �3 2h 1-68 Rev. 5M # SAN JOA LOCAL HEALTH DISTRICT /7ti 3M