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*- .- OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------- Permit No: L---,-3-v-4 (Complete in Triplicate) -----------------------------------------_--------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the SorgJoaquin Local Health District for a permit to construct and .install tKe-work herein described. This application ism +de in�,compliance with County�Ordihance No. 5.49 and existing Rules and Regulations: JOB ADDRESSjLOCAT++IONN,f Z—W----- (------1'-AAK-----Doa I_ INCn7_ VC�-----.------CENSUS TRACT ----------------------- Owner's Name ------C 7Z-V(,1:-� "c!�?T-------- OSS% C0'-------Phone----------------------------------- Address C a.0 T'-- -5 ----`�Z --�-`--f�t1 ---------•--- City -- `�-�G ?1��-----&/1...... -------------------------- I Contractor's Name-'I "l_ _ rl 1 _[- ____� ____t_ _ ._________.License # -IMV ` f l----- Phone,4�? f_. Installation will serve: Residence ❑ Apartment-Floe-sWE]`Commercial :[]Trailer Court ❑ A Motel ❑Other Number of living units------------- Number of bedrooms -----._.----Garbage Grinder __________ Lot Size -------------.___.________._______--__--____ Water Supply: Public System and name ----- 4-------- -----, ___ __ �..___-1;10-c- -- Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt 11 Clay ❑ ' Peat❑ Sandy Loam ,E] Clay Loam Hardpan ❑ Adobe�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 pie mitted if public sewer is available within 200 feet,) 'ANAr`.N , lYt`"t. t I .1 °' �c--'- ------- Liquid Depth -' --f r------- 1 PACKAGE TREATMENT [ ) SEPTIC TANK' Size_ ^_ a__ _ -_ �. t ! 1 Capacity /260_6A_L, Type - i1WoT- Material-_0-000,W1-V-%No. Compartments Distance to nearest3WeIls 1..1f f _____ �r.Foundation -10-"_____________ Prop. Line ___S __:________ ' LEACHING LINE [ ] No. of Lines _ _� '^`�`c` t _ Length of each line._____ _____________ Total Length :_7 �_.r a s D' Box �l_. _____ Type Filter Materia!l�1�_��l26G1+Dep#h Filter Material -15-1 Distance to nearest: Well __!_Y 6?IV_Cr^______ Foundation /0---------------- Property Line -5-0............... ' SEEPAGE PIT [ ] Depth ____________________ Diameter ________ ______ Number ._ ------------------------ Rock Filled Yes C] No 0Water Table Depth ----------------------------f--------------------Rock Size ---- ------------------------- Distance --- ------------------- , i � i Distance to nearest: Well ---------------------------------.------Foundation -------------------- Prop. Line --------.•------...... REPAIR/ADDITION(Prev. Sanitation Permit# ----------�---.___�._ _s___- --__t_ Date I . . .� x Septic Tank (Specify Requirements) --- ----- -- ------- ------------------- ----`----------------- - ----------------------------- ' Disposal Field (Specify Requirements) ____I______________ # 4_ -=--------------------- --------------------------------------------- ---------------------- -------------------------------- ------------------------ I-------------------------I------------------------------------------------------------------•--------. � --e --------- - I----------------------------------------------------- ----------- --------- (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 i County Ordinances, State Laws, and��Rsiles"and xQulations df)the°San,-Joaquin"Local Health District. Home owner or licen- sed agents signature certifies the following: % ■ "I certify that"ithe performance of the work for which this permit is issued, I shall not employ any person in such manner as to becomd s biect,to Work 6n's Com ensation laws of California." Signed -------- ------ ---------------- -------•--. Owner j BY ------` C- - --------- -- --- - Title ------ f other than owner) FOR DEPARTMENT USE ONLY j APPLICATION ACCEPTED BY .w_ ------ ------------------------------------------------------------------- DATE -- � --a��----------- BUILDING PERMIT ISSUED -------------- ------------------------------ - ------------------DATE ---------------- ----------------------- ADDITIONAL COMMENTS - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- ----- --------------------------------------------------------------------- F Final Inspection by: ----------------------------•---------------------------------------Date - "'--='---'-L---- -------------------- --- - -- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M