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FOR OI=FICI: USE: APPLICATION FOR SANITATION PERMIT d :.......................................... . Permit No. ....7..3_�.--.a p (Complete in Triplicate) .............................................I........._. F .. •........................................................ This Permit Expire- I Year From Date Issued Date Issued ..11.'s:.�. Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 2 � Z I JOB ADDRESS/LOCATI ,:...........:....... .. ..... .... ---_......._..__.......CENSUS TRACT .. :1:.:._._.,....._.... Owners Name-..::... .._ ...........-•------...p _Phone f --- ---------- Address >:Z 2 — _� ................. .. --------- .......... City: _ ........ .. ............. .............. c ns ... ...•........ Contractor's Name.....,_ ' �`'�-pG :.L #� � Phone' ' < Installation will serve: Residence-2j'Apartment House 0-Com mercial O'Trailer Court ] r Motel Other -----•--.. i C] ms Gorba a Grinder',.....__. .. Number of living units ..... Number of bedrooms ... g ... Lot Size ...... .,------......... '~..-•---- Water Supply: Public System and name ._.....----- •.................... . ------....,.. ------------- ---•- . . , .._. .. _-- -...Private - p Character of soil to a depth of 3 feet: Sand n ilt❑ `Clay Peat Sandy Loam'o 4 Cloy Loam.0 Hard a 1 � Hardpan Adobe[] ...Fill Material ....._... If yes,aype _ ....._--•--.._.._. (Plot plan, showing size of lot, location ofsystem in.relation to wells, buildings, etc. must..be .placed;on, reverse side.F NEW INSTALLATION: (No septic tank or seepage pit perrriltted If ublit.Sewer is available within 200 feet,); PACKAGE TREATMENT [ ] SEPTIC TANK[ ] SEse.:.....:-�. --- : Liquid Depth ...:....... ---- Capacity ...................... Type ......_ Material-:-.---------- No.' Compartments . . ` Distance to nearest: Well Foundation .......... ..- .__ Prop. Line'..................... EACHING LINE [ ] No. of lines ________________________ Length of each hne..._"..... .--------- Total length• +. ..,., Y......,..._. Z D' Bax '.'Type Filter-Material ......Depth 'Filter"Material"......._- ..................•- `:...... F ..... + _ Distance to nearest Well " _:___..:_ F_oundbt:idn PsopertyYLine -. ___-______: SEEPAGE PIT `( j .Depth ................F_-: Diameter '•..... Number.,..... ...................... Rock Filled.;.Yes ...No {] Water Table Depth---- ---_-----------_-------- -------- .Rock.Size ........•........... _. ' ........... R Distance to nearest: Well ......._._.�..............:...<__ _.. ..Foundation Prop line REPAIR/ADDITION(Prev. Sanitation Permit # .... Date :---......} Septic Tank (Specify Requirements) :......:........... ............ _--•.. +..- ----------.• i Disposal Field (Specify Requirements) .._ ._ -.....-. ...• •• --_--- ................ ...... ------- ........... ......... ...... .. - ................_..................................._....... -- ................._._......... ......... (Draw existing aid required addition 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: . F t. l "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." Signed ne By ......................::........_...._...-----._ Title .:.: ..... cam,.._.,:.... _._.., (if other than-owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ -- --- .rte __ .............. = DATE._h ..lr.; BUILDING .PERMIT ISSUED :_...- -""-- D _ . .� :- . ... . . ATI: r ADDITIONAL COMMENTS . _..._------- ......... ... _._ ... :.... _ i . .: .... ......... ..................e ........°j.•;' ................ ... . .. .. . . ......................... .._.•__•_ ........_ __•__•-• ....... .. ....f............... : _ .... ...... ....:. .... ' . �.. �, ........ ............. ........... ................... .....-. .............i_. .. i Final Inspection by: . ~►t r --- ... --....... .................Date 1 :,. •---..,_. SAN JOAQUIN LOCAL HEALTH DISTRICT c u 13 24, ,&a De.. jziu 7/72 3 M