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rwK vrrit,c uat:' APPLICATION FOR SANITATION PERMIT .. . .. - -. . . . . Permit No. ._L.��_---4�/�4 (Complete in Triplicate) �.. I This Permit Expires VY+ar�F-om 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/LOC J Z/—. I ------------T �fz - l2 p 6 ..... .. ...... ... ............... _ -..............CENSUS TRACT' ......---.-............--- Owner's Name ......... ....0h -------A .Ela, 41... ........--=-----•--•-•---•...- ....., :....:....•....._.....Phone`...._.......... Address . �/Y1. .............. / City / .l..f: .........._...._....__.._.. ...... Contractor's Name ---•--- Cr.} //`- ..................................License #`��{s �//� --- Phone�� Installation will serve: Residence❑Apartment House Commercial❑Trailer Court 0 Motel ❑Other..........................._............... Number of living units:•.._! __... Number of bedrooms _......Garbage Grinder ............ Lot Size / ...F................. Water Supply: Public System and name ......-••.......................................... ....—...................................................Private Character of soil to a depth of 3 feet: Sand Silt❑ Clay [] Peat❑ Sandy Loam {] . Clay Loam ❑ Hardpan p Adobe•p Fill Materlol ............ If yes,type............... ............ (Plot plan, showingsize of lot, location of system in i v y relation to wells, buildings, etc. must be placed on reverse aide.) NEW INSTALLATION: (Nonseptic tank or seepage pit permitted if public sewer is available within 200 feet,) , PACKAGE TREATMENT SEPTIC TANK{ Size � � Liquid Depth ..... ........... Capacity 1�d------ Type MoterialL� No. Compartments .......... Distance to nearest: Well .._.=SaV.....................Foundation ..Z_._......._. Prop. line ................. LEACHING LINE j No. of Lines ...__2............. Length of each)Ine.._._,70............... Total Length 1.Irv-1/0 'D' Box ...1...... Type Filter Materia .20 _..._.--..Depth Filter Material 141 --------------------___.--..._-_-- Distance to nearest: Well`..,=-�O. Foundation --� ............... Property Line -.��._..._____:_:- SEEPAGE PIT ( } Depth Diameter -- ------------- Number ..._.--.----_---.-----.-__ Rack Filled Yes ❑ No ❑ Water Table Depth ----------------------•----- ..................-Rock Size ...........-_.................... _..__ �.' _ .. Distance to nearest: Well ................... --------------------Foundation ... Prop. One .................... REPAIR/ADDITION(Prev. Sanitation Permit# ----_----__--------------l-`_••._----•-- Date -----------__--.-_.- ............ Septic Tank (Specify Requirements) --------------•-...............................•------------................----• } ......---.-----....................... Disposal Field (Specify Requirements) -----•--------- - ------------------------------------......... ...... ........... --------------- -----_----_--.-_ -- --------------------------- _w. .. (Draw existing and required addition on reverse side) d I hereby certify that I have prepared this application and that the work wily be clone in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the Sar► Joaquin Local Health,District. Horne owner or licen- sed agents signature certifies the following: t ' "I certify that in the performance of the work for'which this permit is issued, I shall not eei+pley any person In such manner as to become subject to Workman's Contp sation 'laws of California." j y "'l Signed ._- -.,Owner------ ---- wner.----- ---- By ........ . ..._...--- itle (if other than ow erl FOrtEPARIeNT USE ONLY—a " APPLICATION ACCEPTED BY •. . ._ -- --------•------------ -------- ------------------- DATE .. . ..� ------•---- BUILDING PERMIT ISSUED _ BUILDING ----------- ------`------- ---.--.........._.DATE ----- �,yAD #TiONAL COMMENTS '•-•-----=- ' .. �f_sf�•4L � .._.��,rcrLi. - _ ,�- v....:........... -------------------------------------------------- --------------------------- ... ----------------- .................................................................. --------------- -- - bY= -----. Date . .- ..�._ .-. �7,er. ............. .. 4-68 Rev• 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M