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1AOR OFFICE USE; i APPLICATION FOR SANITATION PERMIT �-•---... ...•--••--........•-•--... �d ' {Complete in Triplicate} Permit No. •----•---.,..................................._•---.---- This Permit Expires l 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,T complio ce with County Ordinance No. 549 and existing Rules and Regulations: q„ ,r• moi• JOB ADDRESS/LOCATION .._.�!�'! -•--•....... ... ........ ....... ..---••------CENSUS T``R'A��CffT Owner's Name phone7r ."! 7��.... ..--------------•---. �•.�� Address -------- ..........9.6- --•---- -- .�''� .....� City ..� GQ.. . Contractor's Name .......... ... ............ ,r-. �--_..License # AiW._, Y....._ PhoneC/v_6... Installation will serve: L Residence Apartment House-[] Commercial❑Trailer Coin • ff Motel ❑Other'_...._._..-•---------"'=�.-.-•• -- � ".� •.. �,. Number of living units_-( -- Number of bedrooms ...(...Garbage Grinder ............ Lot Size ........... ��'t -Private Water Supply: Public System-dnd name — -.... •� t Character of soil to a depth of 3 feet. Sand 0 Silt 0 . Clay ❑ Peat❑ Sandy Loam .[3 Clay Loam.0 HarcipanI& Adobe 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 sept4tank&'seepoge pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT't{ ],. SEPTIC JANK .S, e..... ------- .--._-- Liquid Depth f gcapacity, b ----- Type I-?rte--------- Materlal.(f0�'__. No. Compartments ._-),.------- - I Distance to nearest: Well --------sl,.�1�`..............FoundatiorviA..4___1`'._.. Prop. Line..../_P."f-.___6 LEACHING LINE No. of Lines,,.#_..)'"'-._--__... Length of/�each�line.....Atra............. Total Length..2.1�............... D' Box .r_._ Type Filter Material .....te ............Depth Filter Material .._,�cQ...............................•_ } Distance to nearest: Well _.-. 4_.+'._.._ Foun—datio�_0�'=:4.-O--� Property-Line _.. Q..' ......... - I I R&k Filled Yes No SEEPAGE PIT Depth --.',� y._-.--- Diameter _ '._..._• Numrtiet :" .__ ^'.:_ .._,fie Y, 1 r, fpr Water Table Depth ..............................•..............--•Rock Size' _�c__._X_. l] Distance to nearest:Ut�eII.Ti.. .1 r-''........... . : ��" .- p. . Foundation _._ICs...__.... Pro Line...... ............. 4 REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ---_•_--._---_-___.t. .-----_._...) SepticTank (Specify Requirements) .... ..................................... -•----•-••--••--.•----...--•-••--••-• .............._......................... Disposal Field (Specify Requirements) ............................................... -••---1-•-•---- .......................... ...........................................................=........................ � . {Draw existing and,required addition an rever3bfsid6) I hereby certify that l 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 "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:"- -- -- - r „ Signed .•-----. . `... Owner ,.,{L+� `� �� 54+x'��./ rayl`• ��,,• � f BY �... ' (If oth an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. ----� -- -- _ -..--.- .--_-------. DATE ----......�. �!.�. -_BUILDING PERMIT ISSUED ................................... .DATE ....................._..--------------_--- ADDITIONAL - _ADDITIONAL COMMENTS ...... ••--.... ............................ ------•--•---••--------------........................................................ ........... •--•---••-----•---------------------------......................... ---••--------------• ............ ..........................................._......................................... ........................................ ..................... ...... ...................................... .. r . .._. -- ------- ------- - - - •-- Final inspection by: .. • _ - ---------•......... ................. ..••-•---• ... Date ...... I SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M