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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ......................•.... .............. ............................................... This Permit Expires 1 Year From Date Issued Date 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/LOCATION ,.91YKs?_9.f._. c_ f f .. _. ...........................CENSUS TRACT ..........._....-_........ Owner's Name ........ G ,f �. ../�t_f100-� �'..�.... ......................................................Phone .................................... Address .......... '... City Contractor's Name .... la-�Iel,l�--------------------------------License # �� '�.. Phone Installation will serve: Residence X Apartment House❑ Commercial ❑Trailer Court 0 Motel ❑Other .......___•------------------------------ Number of living units:.../----- Number of bedrooms __A....Garbage Grinder/k.0_... Lot Size A�71 _- oW_................... Water Supply: Public System and name ................................ -----------------....___------------------------------------------------Private [� Character of soil to a depth-of 3 feet: Sand Y] Silt❑ Clay ❑ Peat❑ Sandy Loari 0 Clay Loam ❑ { „ Hardpan ❑ Adobe C4 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 246 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f Size--------------------- ----------------------------------- ... Liquid Depth ......____........... S Capacity .................... Type -----------------__. Material---•-----------_---- No. Compartments ...................... Distance to nearest: Well -.---- ..,.......Foundation ..------._._•--------- Prop. Line ...................... LEACHING LINE ( J No. of Lines ------------------------ Length of each line..--.--------•---_-.---_- Total Length ...._....................... 'D' Box .._ Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT Depth Diameter Number ....... .................. Rock Filled Yes ❑ No Water Table Depth Rock Size Distance to nearest: Well .........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ........................................... Date ..................................) Septic Tank (Specify Requirements) ------------.---- ---------....--•......I........ -----.�R.--- ---- ---....... ........... Disposal Field (Specify Requirements) ..4" / -y.-� reAO.......aY�- � � � ................... 4%11 /. .r.._....-/ .. ------------------------------------------------------------------------•---..._----...--•- -"----"---------------------------------•----.._-._......._...----•----.._.--__-.......----------------------------•---- Draw ex s i and required addition on reverse side) I here y certify that I have prepared this a ication and that the work will be done in accordance with San Joaquin pp a County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home 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 In such manner as to become subject to Workman's Compensation laws of California." Signed •--------------------- ------.... ...........------._..-•-•---------- Owner Cher than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.; k.- = .—------------------------------------------. DATE .Ao_n/ -_?),...... BUILDINGPERMIT ISSUED ............................ ------ .........................................................DATE ------------................_..._._ ....... ADDITIONALCOMMENTS ........ -••--•------•-----.....-•-•----••-------------------•----------- ............... ............................................................ ...._.. ...................................................--.......................... --........... ....... . ................. ........ �^ y Final Inspection by: ........ ... --•-- ----------------------------..-----..............................._.Date ,�1� -- . SAN JOAQUIN LOCAL HEALTH DISTRICT 4 E. H, 1-3 24 1-'68 Rev. 5M 7172 3 '