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FOR OFFICE USE: FOR OFFICE USE: ' t, - APPLICATION FOR SANITATION PERMIT ----- 1 _47,40................ - . ---•-•--- {Complete in Triplicate} Permit No7f r—J--{d g ------------------ ::.._...._.----------- Date issued.V�:7A� _ •...... 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 application is made in compliance with County Ordinance No. 549 aqd existing Rules and Regulations: JOB ADDRESS/LOCATION.. /.... Y CENSUS TRACT...._.: Owner's Name.... .............................. :. .... Phone-.... �. . _ Address � :_- . City--------- ........ -...................- iP--......-.. Contractor's Name....- ..-- . License #4/ -.71 l l 1...-..Phone.- ----- " Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.... ---------------------------- Number ------ ----Number of living units:----- of bedrooms:.P:0 G'rba e Grinder_.-.._......LotTSiz`e---: . Water Supply: Public System and name.--.. --- -- -------------------------------- ------- - -- ........ ------------------Private � Character of soil to a depth of 3 feet: Sand ❑ Silt ElClay F-1Peat ❑ Sandy Loam ❑ Clay Loans E Hardpan ❑ Adobe ❑ Fill Material.. ---. ..- If yes, type-------------------------- - (Plot (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 tank or seepage pit permitted if public sewer is available within 200 feet,) [,[ X. Liquid Depth.--! PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size.. ---------0� Capacity. ...--.. No. Compartments--._ - -.- P � a�-f�-Gr- .TYpe._.. _ - '- -Pro Line_ .... . _.. . . Distance to nearest: Well..............- Faundation._.� -. . -- P LEACHING LINE [ ] No. of Lines. - -. ---------------Length of each line.....- - ~-- Total Length . - -------.--- - 0 - ----••------------ . •-_....w,. D' Box .Type Filter Material;._-..... ...Depth..Filter Material__��-..-------- ..__. , Propert Line.... ---- ---- Distan to nearest: Wel!_- - Foundation.... .. .-- ----- - Y Depth ., Diameter.. . bf----Number---- ------------ ---- Rock Filled Ye� No❑ SEEPAGE PIT [ ] p p� 6d . ,•�-" II Rack' Size . - Water Table Depth.---- 6 4 3 Date- on._-- ------ -.Prop. Line-- ----- ------------- Distance to nearest: Well.--- - -- ---- ---•-Fo.undati . REPAIR/ADDITION (Prev, Sanitation Permit ---------------------------_---- -��----------- Septic Tank (Specify Requirements)----. . .. -.. -- - ------ --------------- ----------------------------- .-------- ------- ---------------- Disposal Field (Specify Requirements). - ...... ,-•- - ... ... •---•-------- -------- ------ G - --------------------- (Draw existing and required-addition on ieverse 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 licensed 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 Compe aws of California." s - ------- - ---- _-------- wn Signed4� ------------------ By--------- -- --- ---- i ( f othe tan own r) FOR DEPARTMEN USE ONLY DATE ....- � .� ... ... APPLICATION ACCEPTED BY.....\-- -- - ----- ---- ------------ ----------- --------- 4 .. . DIVISION OF LAND NUMBER------ --- ---- -- ------- - DATE__ --------` .... . . -- --- ---------------- -------- --- -------- --- ADDITIONAL COMMENTS .............. _.....................-........................ -------- ----••---•-------------...----.---- ---- . _ ------ ---Date..._-.. . .ZS. � - Final Inspecrnon b ----= - -- -- --- Y' �� I F85 29677 REV:7/76`_3M G EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT