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4 FVR OFFICE USE: APPUCATION FOR SANITATION PERMIT (Complete In Triplicate) Permit No. ....�_•�....... C ....... This Permit Expires ] Year From Date Issued Date Issued ,... y .7(- F $ i Application Ii hereby made to the San Joaquin Local Health District for a permit to construct and 'Install the work herein described, This 4application Is made In compliance with County Ordinance No. 549 and existing Rules and Regulotions, Ilk JOB ADDRESS/LOCATION ...7- 6.-/A�7-t &-- ___J_-_ • ,-- (f , .......................CENSUS TRACT Cn+vner's Name {M.�..... �ivl!`� ... Phone Address .... ........ ........ ------ ................................................. City .- .. ........ Contractor's Name - ¢!:( •_ `�O C ��_ ' ..............-License # d 7 � Phone . ---- Installation will serve: Residence Apartment House{] Commercial❑Trailer Court 0 Motel ❑Other ........................ .Number of living units: ..3.-_ Number of bedrooms . Garbage Grinder _ Lot Size _-.v2C - ��5 Water Supply: Public System and name ..:................................................. Private ._.. -------------------•---•---------•-- Character of soil to a depth of 3 fee ----•• t : Sand ne Silt❑ Gay .❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan p Adobe❑ Fill Material............ if ,type a..............: ............ Y (Plat plan, showing size of lot, location of system Jn relation to wells, .buildings, etc. must be placed on reverse side.) NEW INSTALLATION: {No septic:tank or seepage #t permitted if public sewer is available within 200 feet,) V. - . PACKAGE TREATMENT' ` SEPTIC TANK fYlr� � .......... liquid. Depth ------------•--------••--•y .� ._ GG .J r��d �j¢( .i�, Capacity / --------- Type tna.�rC.�__. ,. Material.�dltCtl�. No. Compartments ...................••. �X r,Sy�� y IDistance---.to nearest. Well _:. 3.......... .............Foendation --�Q.7f- -_---- Prop. Line S f ...---.-- LEACHING LINEs No" of.Line --_- '. F ` r�...---•-'=--'----'Length.of each fine--- .............•-- Total Length .�d_,................ D' Box �e �/� f"OA!,w Type Filter Material/.�.: '.�F<Depth Filter Material 2-Q.................................I...To '/ Distance #I ¢ r / / to nearest: Well _- `C�-f....._.... Foundation /Ct4!........... Property Line .......... I I'- ` � SEEP th <>.. _ -------Diameter -------- ------- Number ............................. Rock Filled Yes ❑ No i❑ fi h ....:.....................••---------------••--.Rock Size .-•--•--..... .................. 4 e#I •----•---------------•---------- .----..Foundation .................... Prop. Line ..------•-----......... t REPAIR/ADDITION{Prev. Sanitation Permit-# - -------- -------------- ------ Date --............._.- ............... Septic Tank (Specify Requirements) ...................... --------.......-•---•-••------=......---........---•--................... Disposal Field (Specify Requirements) fOQ. L_._.._== g`8 r ----......d ---------------------------------------------------- ••_--_-------- _......---_-d,;..6...-.-. =•-_------------------------•_.-..-..-..-_-•-•_-...--_-.......__-••---••-__•--. ---.............--.-P r ----------------------- •-- .w .......................... (Draw existing and required addition on reverse side) - 1 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 t 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." SignedOwner ------------------------------------- Title . ----- (If other than owner) 'r € �F," DE�PARTMENT Lf5E ONlY APPLICATION ACCEPTED BY ` ........... ---. -- DATE T -..-..... -•- - BUILDING PERMIT ISSUED . ..----- t..•---------- ------ •---••-------------------- ---.-------.DATE ....----_-- -------------•-:..... DDITIONAL COMMENTS ..............'-----:-------------------------------------- ..-----...-.---......:..- - - .- --------•-••---------•-------------------------••------------------ -----------••-------------------------- . :: --•------------------------------------------ -................----------------------------------- ----------- :. --------------------------------------------------------------------- ---------------------------- ---------- �..,._- ..................:................••-......:...--- Fina! Inspection by: ..------... ._ _._: •---=-.:...--•---.. .-- -----.--------- - ----------------Date .- .. .. •- - �-•-----•--.... EH 13 2!t 1--68 rev. s . � � j......:.......... SAN JOAQUIN iOCAL HEALTH .DISTRICT 8/7h 3M