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VUR OFFICE USE: APPLICATION FOR SANITATION PERMIT z (Complete In Triplicate) Permit No. ................ Date Issued ..........•••--- ..----•-••.....................•.----_---•- This Permit Expires ] Year From Date Issued s! s� Application is hereby-made to the San Joaquin Local Health District for a-permit to construct and install the work herein described. This opplication;ls made in compliance with County Ordinance No. 549 and existing Rules ondRRegulations: JOB ADDRESS/LOCATION ---- �C 'X�QC�.�bv "d-3 3 ------•-• --_.. ...................._....._..._,. '.1?/_, 2 ................CENSUS TRACT i_....._...............--- Owner's Name _ .. ��-•---Js91V ��` ..................... -----�• -•---•�---••................................Phone ....... .. Address . . .. ... rT.f_. .. 1 _Cr I�.N ..../ :.1/(1.........:..:.t City .. C� `. .�w �» 4=................... Contractor's Name -.----A - - ?G2-� ...............................License # �.r�4..tJ.�lc1 Phone Installation will serve: Residence C"Apartrrient HouseO Commercial ❑Traller Court 0" r` Motel ❑Other ............. Number of living units:_./------- Number of bedrooms __:3.......Garbage Grinder ...I.... Lot Size _-"b...:'�_ :....... Water Supply: Public System and name a h ...Private` _•_•_-_......-•___••......................... .........................A................................... Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat 0.b Sandy Loam N 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 permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT Capacity EPTIC TANK �� "�/ q p �1 [ a l 3 Size._: _.-Li uid De th ,... ...........- f G"" Type lO "•-•-----�aterial-------------- - ---- No. Compartments .. ,,. t _ Distance. to nearest: Well .r.,E�.......................Foundation _-/ •••-• ------_. Prop. Lined ............. 0 LEACHING LINE [ J No. of Lines �y ---- Length of each line____.. �.......___- . Total -Length ..�� ... --....... 'D' Box J.------- Type Filter Material /_folcro?�Depth Filter Material ..��.......:...... .......`.......... 1 Distance to nearest: Well __��- Foundation -.v'�.3..�__._.. Property Line;-. CF..:........... SEEPAGE PIT [ Depth -------------------- Diameter ---------------- Number .---------_------_---_ Rock Filled Yes ❑ No ❑ Water Table Depth ------------....................................Rock Size ................................ O+ I tV Distance to nearest: Well -----------------_---.-------_--_-Foundation ------..........__ Prop. Linfe ...................... p+ REPAIR/ADDITION(Prev. Sanitation Permit=# ....... --- ....................__ Date -------_.......................... } ; Septic Tank (Specify Requirements) - ...... s Disposal Field (Specify Requirements) ____________________ I 'y - •........................• -•-------------........-•------------------. ------ -- .............. -----------------• -------------- i r % = -----------------------------------------------------------------_............. - ' (Drow existing and required addition on reverse side) I hereby certify that I 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 San Joaquin Local Health.District. Homo owner or licen- sed agents signature certifies the following: m "I certify that in the performance of,the work for which this permit is Issued,-1-shall not employ any person In such manner as to become subject We mars' ompensation laws of California." Signed ....... i .- Owner BY ----- --------------••-•------------•-• ------------- Title Of other than ownerl FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED SY ---------- - ------------ -----•-•- ---• 75 . ----------------....-----._..._._._._.. ._. DATE ----------------------- BUILDING PERMIT ISSUED - = DATE - ------••------------------•---•---------------•-- ----•-- ---.... ADDITIONAL COMMENTS ------------------......-------------..._._ ------------------------------------ --•---•--.--.--,,,-----••-----------••------•--•--•---------.----------•-------......---- . ......................................... ------------------- --- •--- �• Final Inspection by: ..............................DateEli _... � f . 13 2L 1-68 diev' 5mSAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M