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FOR.OFFICE USE: . APPLICATION FOR SANITATION PERMIT S3� ....................................a............. Permit No. .. 4Complete In Triplicate} --- 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 mo-1- in�co �p�iionc with Co rdinance No. 54and� istingRulps and Regulations- JOB ADDRESS/LOCATION -------F1 7r. .._e _.f......... :..:.1,.._1f...l.v...CENSUS 7R.ACT .......................... Owner's Name .Z)A!5 --------/ -------•---•..........................••--•................................................Phone .��. :.. /..�.F.... Address Z-21.1.._ <9cJ2P/^r ._..City,L59&1�.......... Contractor's Name ........... � �1./' .......-•-•---•-- ......,License # f+ ...... Phone r3'G ... Installation will serve: Residence W Apartment House❑ Commercial❑Traller Court ❑ �- Motel p Other _..... .............. ---.. .....--•...... Number of living units------I----- Number of bedrooms —3 Grinder .......... Lot Size ................• Water Supply: Public System and name ......------............................................_....................................................Private IR Character of soil to a depth of 3 feet: Sand 0 Silt❑ Gay 0 Peat❑ Sandy Loam 0 Clay Loam ❑ Hardpan e Adobe 0 Fill M6terial ...._. ..... 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 Itank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT .I j SEPTIC TANK 116-ef JA.r� Size .4... .......................... Liquid Depth .......... ................ a Capacity -------------------- Type .................... Material ..................... No. Compartments ....................... Distance.to nearest: Well .................. ............. ..Foundation .....---.............. Prop. Line ...................... LEACHING LINE ( j No. of Lines ------------------------ Length f each ine---•........................ Total Length .........-_ ................ 'D' Box ...I-------. Type .Filter Mater! ......... .........Depth -Filter Material ............................................ i ......... Distance #o nearest: Well -•--------- ----------- oundation _...----•_...--•----.-.. Property Line _..----........ SEEPAGE PIT [ ] Depth ..-•---------..---. Diameter ------------- -- .Number ......---------------------- Rock filled Yes 0 No C) Water Table Depth ........ ------------------Rock Size .................... ----------- Distance to nearest: Well ___ :Foundation I REPAIR/ADDITION(Prev. Sanitation Permit�# _______ _______________ ___•----•-•-.---•-- Date ........--- } i Septic Tank {Specify Requirements} .............. ----------............................ -------------••-----•-- ---........... ••••.................. Disposal Fie 5p cify Requirements) . 1 �.... --------------- ._........._... , % A . ... Via.... .. :. 5 �7? �� ------------------- ------ (Dravdexis rng and required additi 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;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 oorkmanmpensation laws of California." Signed ---- o ----------------------------------------------- Owner BY ........................................................ ......................•----------......_ -..._.........--• ............_.. Title {if other than owner) ` FOR JWPARTMENT USE ONLY APPLICATION ACCEPTED BY -----...- ------------- DATE BUILDINGPERMIT ISSUED ------ ----------------------------------------------------------------------- -------------•------••-,-.DATE .......---._ ....................... ADDITIONALCOMMENTS --------------- --------------------------------- ......................---------------•-•------------------------------------_.......:._..--------------- ----------- ------ -----• --- -------------- •--------------- -------------- --•--------.-... -------•----. ........................ .... _ .-------------------..._. ---------•--------------------- --------- / ... . ........................ Final Inspection b --- --- _ - -------------------- .._.....__._Date .� /� .- -- EH 13 2� 1.68 SAN JOAQUIN LOCAs. HEALTH DISTRICT 8/7h 3M