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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 jy9'Z 1�' WAY 33 CENSUS TRACT ......... ... ........._-......_.._... ...........-..-.._. .. ............................ Owner's Name nr' - - CP.Sr9 ............................Ph one R -r-.. - ......_......_.. ._.....q........ s— ..S�f 8 9. AddressP- s-...-.-AG_o✓_c -'--. - City ................ . ........................-f . -... .- Contractor's Name ------- Ary T/r o iv t 5.0-"V......................License# J 6 6-� G_... Phone --� .�.3. c/A 1 1 -' .............. installation will serve: Residence r$[Apartment House 0 Commercial OTrailer Court D Motel []Other ' ....... --'• "'•'- .............•.. ,7 Number of living units:..--- ..... Number of bedrooms ....L......Garbage Grinder ............ Lot SizeAcyQ S ............................................ Water Supply: Public System and name ............................... .......___...................Private Character of soil to a depth of 3 feet: Sark!0 Silt 0 Clay 0 Peat 0 Sandy Loam ® day Loam 0 ( „ Hardpan❑ Adobe 0 FIII Material ............If yes,type............... ............ (l; (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,) VVV PACKAGE TREATMENT [ ] SEPTIC TANK( ] Size........................................ Liquid Depth Capacity .---------------- - Type .................... Material."'•""-'-'-'....... No. Compartments ."'..................Y-1 Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE [ ) 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 0 No 0 Water Table Depth ...----.................. .....'-'-""......--Rock Size ........................ ' _ Distance to nearest: Well ........................................Foundation ............... Prop. Line ...................-.. REPAIR/ADDITION IPrev. Sanitation Permit# ............................................ Date _.........._.-.-................I Septic Tank (Specify Requirements) P P fN ' ..................z�_......�� ..T'b....�/......4� r..ch hiwc 36 '. ti Disposal Field (Specify Requirements) .....W='Ae-.....4_N......EX 5__r/ncf....s-�1?'T c -TAiy /S' -- - - ... -------_------------ --- ------- _ -------------------------------------- .......................--- ✓' ....... . ...........-............._........._........(C - --------------------------------- - --------- ---- - -- - . .... . .. "Y ` (Draw existing and require- d addition. . on. ..reverse. side) 1 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 Son 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 Workman's Compensation laws of California." Signed ..-- -.--- . — Owner C4 By -. - - D1c--- ------ - --- --------------- --- title (If other t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �--------------------------_----------------- ------------ DATE .. SW7&---------------` BUILDING PERMIT ISSUED - ---- ------ ------------------------_. ---- . '-------------------------------- .... _DATE - - .. .. - ADDITIONALCOMMENTS ---------- - ...........'---' '---'-- ---- --........... - - ...-------------------- - -- --------------- --------------------•----------------...--------------------- ..........---------------------... ....._........--..-.. -'---- .......... -- -. - ----------------------- ----- - ----- -----' . - ------------------------------------------------ -------- . Final Ins ection b --'----'------- -'--------'------..- ...... . ... . ..------.Dote -.. ... P y: ----------------- -7.. . .-...... - EH 13 2b 1-68 Rev, 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 8/71r 3M