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FOR OFFICE USE: APKICATION 1`ORNSANITATION PERMIT lc/ //,'ct, V -4 s Permit No- --- -------------- --------------------------------------- (Complete in Triplicate) --------- ---------------------------------------------- Date Issued _G_-__a:----_--- f This Permit Expires 1 Year From Date issued f 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: JO ADDRESSC/LOI ;(N ------ --- - ------ - ----------------CENSUS TRACT ------------- Phone ------------------_- --------- OwIn er's Name ---- --4- � --------------- ------------------- / Y � - --- A------------ .............. Address ---------� � -------------- e- ------ - 'fCit -- ---------- _ Contractor's Name ______,fir --------D --- -- - ----.License # .mac _ Phone `1 •� Installation will server Residencepartment House,[UComrnercia`E]Trailer-C-ourt- ,0 Motel ❑,Other ----------- lt' rGarba a Grinder -- ---- - Lot Size ------------;----- -------------L. r Number of living units:-------- Number of 1� c [`�_ --;Private ❑ Water Supply: Public System and name __A_____________ -----..-. -� Chalracter of soil to a depth of 3 feet: Sand'❑ Silt do Peat❑ San jr Loam Cl Clay. oa ❑ r Hardpan ❑ Adobe' Fill Material _�d_ If yes,type ________________ e (Pio{ plan, showing size buildings, etc. must be places. on reversside.)of lot, location of system in� lotion to wells, if NEW INSTALLATION:7Z(No septic-tank»or seepage-pit permitted if,public sewer is availew within 200 Aetl 1 PAdKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------ ------------- tLiquid Dep __..----------- _.-------- - Capacity _- Type -------------- Material------- ---- Na.kj Compartments -----.. Distance to nearest: Well ---------------I---------- ----Foundation ------ -------------- Prop.tine ---....---- ---------- Len ' -------- I ----•---•------ -----•---- LEACHING LINE [,] No. of Lines _______________________ Length �af each lin � � ��-1 -y ---------- Total Length __ D' Box ------------ Type Filter Material ----------------_ _ _ epth Filter Material _____________ v Distance to nearest: Well ________---_____i____ Foundation -t----------------- _- Property Line SEEPAGE PIT [ � Depth -------------------- Diameter ---------------- Number ---------------------- -- - Rock Filled Yes.[] �No ❑ Water Table Depth ---------------------------f ----------Rock Size ----- -A WAS Distance to nearest: Well ---.--------------- -----Foundation ---------_ -------- Prop. Line -----•---.--------.--- - REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------- ---------------- Date ---------------------------------1 . SEpfiic Tank (SpeaiFfy Requirements) --- ---------------. --- -- � --- - ��-� Disposal Field (Specify Requirement ) - - -----� --- {= . .........,,� . .--� I ------------- ------------------------------------------------------ ---------------------- ----- Ir -------- ---- - i.,------------m-------------------------------- ------------------------- ---------- (Draw existing and requir addi.iongon revere a side) I he eby certify that I have prepared this application and t at the wo& will a done in accordance with San .llaquin Cou ty Ordinances, State Laws, and Rules and Regulations of the Sankoaquin Local Health District. Home owner or licen. sed gents signature certifies the following: 'A 11 "I c tify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as t become subject to Workman's Compensation laws of California." Signd 1 Owner ------ - ------------------ r------ Title -___)/-_e---- - --- '40 � ---------------------------- BY -- --- --------------------------------- ONLY (If other tha ner) EPARTMENT USE r � APPI ICATION ACCEPTED BY . -%, ------------------------------- DATE .�lti BUIL ING PERMIT ISSUED ----------- - --- -- ----------- Jr : -- -- ------------------- ---------------DATE --------------------------------I--------- A D TIONAL COMMENTS - d--� f ---------- --------- ---------- Y -- ----------- ------------ �� --------------------------------------------------- ---------------------------- ------ ---------- -- --- -------------------------------------------------------------- -- ------- FinaInspection by: r -ar- ------------------ --------------------------------------------------Date -- � --------- -------------------------------- --- ------------------ --------- JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M t _