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FOR OFFICE USE: APPLICATION FOR SANITATION PEP'-T / (Complete in Triplicate) Permit No. _L.z/OGS 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. 5549 and existing Rules and Regulations: i. JOB ADDRESS/LOCATION �� _ 7_. _---_C/%/PTC' ....._. I .-_4:-�c_¢-/�(z_�ENSUS TRACT _- _ Owner's Name cca. - -------f-f-V.lhs-----------------•------------------------------.-Phone SX.6_:7 Address .- y f1.cJ �g QZ - - -G�9 P.. - - -------- City - St 1. - Contractor's Name�o...e-fJ. -_�j ------ Qt f3z,S.__-_--, �f/L'_ License # ��. 3 --- Phone Installation will serve: / Residence 3'Apartment House❑ Commercial❑Trailer Court Motel ❑Other Number of living units:----/___ Number of bedrooms .>—P-----Garbage Grinder ..._ __-- Lot Size _ s'G? ---------- Water Supply: Public System and name ------------------------------------------.--- __ -----------------------------------.--------PrivateA Character of soil to a depth of 3 feet: Sand Silt.❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 Hardpan ❑ Adobex 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 publicseweris available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TAN K 4v X�..Y/1--------------- Liquid Depth __�r/_ ..Z--------- Capacity 1�O.___ Type __ / -�<�lvlshaterial__ dcC�C'�No. Compartments _-__ \ pp�1 / r Distance to nearest: Well _p-fl...._-__- ..... Foundation .-./0-------- .---- Prop. Line ._ LEACHING LINE ) No. of Lines _/---------- -------- Length of each liline....j0.- _-_-_--__ Total Length�._...�-o.._---....... 'D' Box ---X...... 'Type Filter Material .�04 ci ....-Depth Filter Material _.-l/-_-________ 4 / � _ Distance to n�rest: Well __�t..�-_-__---___ Foundation Property Line _- -------------- t SEEPAGE PIT Depth _/ .- Diameter/ /w_.-- Number .......... ....._._._. R�o/ck,Filled Yes No ❑ Water Table Depth -G Q-------------_-__._._______---Rock Size ._-- -- ------------- r Distance to nearest: Well _- _ --------------/ ./� -----------.-Foundation - ld --- - _ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -...__.._------ --------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) --------------- ----------------------------------------------------------- - --- --- - r / Disposal Field (Specify Requirements) 4 _L°.__.-__.Qlcf..-__-.-,SL� __4r3 ____________._ ---.- ---------- ------------------------------------ --------------------------------- ------ ------------- �' ------_......_..._..__..----------------------------------------------------------------------------------------------...._....--.............._.................. (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 _ 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, 1 shall not employ any person in such manner as to become subject to Warkma compensation laws of California." Signed i�-rt/ 1�. �. `'P�- Owner -- - ---- ----- -- --- --- --- -- - ---- - - - - ---- ----------------------- ----- - Title .............._....... --- --- ---------- _ (1 other than owner) FOR .DEPA ENT USE ONLY APPLICATION ACCEPTED BY -- e 2:- -------------------- -- ------------ -----------. DATE -.1-2_- _-'_.. ...... - .. BUILDING PERMIT ISSUED --- ------- ------ ------------------------ ------------- --------------..DATE ---------------- ADDITIONAL COMMENTS --------------------- - --- --------------------------------- --------- ------------------------- -------- ------- ----------------------------------------------- - ------------------------------------- ----------------.-.-...-._.......-.-.-...-..._.... --- -------------- -- - ---------------------------- -------------------------- --------------------- ------ L -- ------------------ ----- -- --- /----- - - - - - - - - --------------------------------- - Final Inspection by: ----�.1f:�c_L-- --. C---- �- ------ ------�-------------------------------Date � � SAP JOAQUIN LOCAL HEALTH DISTRICT V E. H. 9 1-'68 Rev. 5M