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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT {Complete In Triplicate) Permit No. ... ............ This Permit Expires t Year from Date Issued nate 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. 549 and existing Rules and Regulations: JOB ADDRESS/IOCAT N �� R /.. .S.sSr...(` -4Lcr,�c•C,�.. CENSUS TRACT Owner's Name i f ......phone . ..... Address . 3`. r.. ----------------- ......_.......... City .. . Contractor's Name ..............license # C1 Phone,..a5.-�.947/22 40 installation`will serve: Residence Apartment House Commercial❑Trailer Court ) Motel ❑Other.......... ..... Number of living units:... Number of bedrooms _ __- ..._Garbo 9 a Grinder _ .. .�Z9? int Size ..�.��1�•�t!!,�,...........:... Water Supply: Public System and name .......... Private� Character of soil to a depth of 3 feet: Sand A Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam.❑ Hardpan 0 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,) PACKAGE TREATMENT / ( ] SEPTIC TANK; � Size---!_a�3.,�.................... Liquid. Depth Capacity _-� .. Type Mater€al.�.. Nod Compartments �,.. • Distance.to nearest: Well ----- '0_..................Foundation . Jam.. . ......_ Prop. Line - Q........W ��{{ i LEACHING )INE [ ] No. of Lines _._.. -_______.__- Len th of each fine-. _ __ p 9 � „ • _ ,�.�....._..--- Total length ._.._�'....................J0 D' Box ------- Type ,Fifter Material ---_-_.__ ..�__ Depth .Filter Material /S. . ..........................� � Distance to nearest: Well _. --------.... Foundation __/57.............. Property line ...f ....... SEEPAGE PIT { ] Depth �^ p ------ Diameter -------------- Rock Filled Yes,❑ No i❑ Number .....................•-•- - Water Table Depth -------------- - .. •--------••--•---------Rock Size _-..........._ ` ----.....- Distance to nearest: Well -•-•___ -------- ..........Foundation ....-------Y_ Prop. line ............:... I REPAIR/ADDITION(Prev. Sanitation.Permit# __._•:`.....__-__-. -------------- Date ____...:.._----....--•-• ] k ................ t Septic Tank-(Specify Requirements) 1 Disposal Field (Specify Requirements] _____________ _ s l ----------••-------------•-------------------------------------------------------------- ------------- — ... ------------••--------------...---------------- ------------ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done An accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health;District. Rome 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 shelf not employ any person in such manner as to become subject to Workman's Compensation laws of California.,, " a Signed -- --------- ----- ' BY :.. . Owner ........-•----• --•------------•--- Title ................ -------------- .--- - - i � (If other than owner) O DEPARTMENT USE ONLY " •`, APPLICATION ACCEPTED BY --- - - — ^�- •- --- ------- - --------•------------------- ------------ DATE ...... BUILDING PERMIT ISSUED .................... DATE .-.---- ADDITIONAL COMMENTS ............ --•-•.........................................-_..._..------------------- ._..-----•------•-•----•--------•---,. -------•----------•-•- -------•-----•------- ----•--------•-----•------------ •----•..............._. .-_ - Final Inspection b - - - . ..................... .. •--- ----- .- ------------...._...-------••-•------.-•------ --•-.. .. . ... .__:.._Date .... _. ..... . --.._ EH 13 .2b 1-68 Rev. 5m ..... ........... SAN JOAQUIN LOCA! HEALTH DISTRICT 8/7h 3M