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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT • / .. -. Permit No 7.../ /. .... r _&mplete In Triplicate) ................ ................ - . . .. _. ... Date issued ._..`..._`a. ....... .._._.. This Permit Expires 1 Year From 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 b U lic�io ode in compliance with youty Ordinance No. 49 and existing Rules and Regulations:CENSUSitACT .......................... JOB ADDRESS/LOCATION ... . --. .... Owner's Name .............te.r...`Phone ......s.... ..._d.l .. ...... �f Z � _..... City .... ..... Address - ------ Contracor's Name __. _ .............•...License Phone ...........__ ' Installation will serve: Residence Apartmen House[] Commercial❑Trailer Court 0 4 , F Motel ❑Other.............................................• bedrooms � F Number of bedrooms �.......Garbo a Grinder Lot Size � ��' ........... Number of livingunits _ f Water Supply: Public System and name -- --- --------------- -------------- ..........................................Private ❑ 0 Character of soil to a depth of 3 feet: Sand❑ . Slit❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ Hardpan p Adobe❑ Fill Material .... ....... If yes,type ........... IIs buildings, etc. must be laced on reverse side.) to we , P (Piot Ian, showing size of lot, location of system in relation9 p g NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is availablewithin 240 feet,► F / i SEPTIC TANK .....:........... . ..--•----_-_. Li uid Depth PACKAGE TREATMENT Capacity .-- Type -*--- -- ------ Ma Tial ' No. Compartments .......... Le h ofa ch-line.__.. - 7-......... Total LengthLine -.0.------•...... Distance to nearest: Well e•. ............ .Foundation .. - 0._.... . .. . 'ar ., ............... LEACHING LINE ( ] No. .of Lines -4--------- -'..--• g 'D' Box /..... Type Filter Material ........•`.._ ......Depth Filter Material /Y...............a ��.m i]istanc6 to nearest: Well -----._.._..--•--.....__ Foundation ...............:........ Property.Line .......... ............. ( � Depth,�)Uel,"�_. Diameter ---------------- Number .......9 ......... Rock Filled Yes No Q Water -Table Depth ------------- •-- -----------._..hock Size ..............� Z •--- Distance to nearest: Well ........................................Foundation .................... Prop. line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -......•........--------••-•-----•-•------- Date _-------- -- .......} Septic Tank (Specify Requirements) ...........................................�.............................` _...., .-------•.......:..... ................. Disposal Field (Specify Requirements) .:-------------- .....................-..............................................................................._- . --• --------------- ------------------------------------------•-••------------------------------------------------------- ...................... ..._.._....------...,,_........• -------- -------------------------------------------------------------•-------- ----•---------------•- (Draw existing and required-addition on reverse,side)" I hereby certify that I have prepared this application and that the work will be dome 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed _.. Owner `D� By ---------- £ - •- • -------• Title ---------- --------'-----.....---..._......--..._----....---'- :_...-- Mer owner i R E ARTMENT USE ONLY DATE APPLICATION ACCEPTED BY ----- -- --- -------- --------------------------------- .. --- - 3 BUILDING PERMIT ISSUED ------ _- ------------------=--- ---------- DATE ------ ---------•- •--- -------- ADDITIONAL COMMENTS - _... .___ ... = .. , .. . -------- ---•-------.-. . . ------�� yr --- -- - ..... .. ----_. ` Final Inspection b --------Date -- r� .. i EH 13 24 1-68 Rev. 5H SAN JOA UIN LOCAL HEALTH DISTRICT 8/74 3M