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FOR OFFICE USE: �` w APPLICATION FOR SANITATION PERMIT .............. ..7:5_�..�,�7 .., . (Complete In Triplicate) Permit No. This Permit Expires 1 Year From pats 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 ._..L1 S..d . -� �,.�"�,-• all ••------ .................... o'"r/............CENSUS TRACT ..... Owner's Name ._ �rc9 ....., ..:........... /� Address ---........ o 2 j' 4 . -ap&V, ._ .-•--•---..city . -- a.......I.......... .......................... Contractor's Name ._ ��_.:...._ License Phone -- --------------------------•---•-••-•............_---•-- Installation will serve: Residence©Apartment House{] Commercial'oTrailer Court �- Motel C7 Other........................................... .. Number of living units:--- ------- Number 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 Q Clay 0 Peat Sandy Foam 0 Clay Hardpan ❑ Adobe 0 Fill Material ............ Ifes a............... ............ �I Y ,tYP � I (Plot pian, 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 seepa9 it .permitted If public sewer is available within 200 feet,) F PACKAGE TREATMENT [ } SEPTIC TANK Si e.....:................... Liquid Depth i ............. ...... .........................-� Capacity ) U___:.____ TYPgP-R! '°• Material.. C ..No. Compartments .... 1stonce.to nearest: Well __rS . ....--•--•-•-••..Foundation ../...O .:...... .... ........... Prop. Line ...................... � X04 O II LEACHING LINE No. of Lines --- --------------- Length of each line 1............ Total Length ....I 'D' Box --... Type Filter Material ` -----.Depth .Filter Material ...... N /yC Gem Distance to nearest: Well iS` !.............. !�. .. .Foundation r ............•..... Property Line ........................ IT ( ! Depth .......... Diameter �!� .�d_f_. Number ..._....�...............'Rock Filled Yes _/ No Water Table Depth -----------••...................................Rock Size ---------- .............. IC Distance toInearest-, Well ........... 4�l.:........• ........... ��, ....Foundation .................... Prop. Line ........:....._...t.. 3' OEPAIR/ADDITION(Prev. Sanitation Permit# ...........----------------- ......... ..... Date __....................• . Septic Tank (Specify Requirements) _ . Disposal Field (Specify Requirements) -------------•-•-- .. ------------------------------------- -^-'- --'-------••---•-•-----------•--------------------•-•--•--...........---•-•--•---.....--.........---.......--------_----................_......... J@raw 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:Dishiet. Herne 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 sub'ect to Workman'sCompensation laws of California." Signed - ._ Owner i BY --------------------------- -------------------------- •--------•------------------------------- Title --------------- .....-----...-- (if other than owner) 1/9 FOR DEOA- RTMENT USE ONLY ti APPLICATION ACCEPTED BY = .... - r DATE . ./-_ .yr.� ._. .__. BUILDING PERMIT ISSUED .............'-:----------------- -------------------------------------------------------------------------- DATE .. - ----- -- ADDITIONAL COMMENTS - -----------------------•- -•-•------------ --•-------------- : ----------•----•------------•-- -------------------- ---- .--..---•-------....... .... --- --• -----...-.__..---I... . ------- _..... ---------------------------------- -------------------------------------------------------- Final -- Inspection by: ........ .� __.. ................................................... .----•--------Date .. ..�...:_.7....... -._..�_r_...... _ EH 3 2 -6 v• 5M SAN JO AQUIN LOCAL HEALTH DISTRICT 8/7h 3M 1