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FOP, OFFICE USE- ......... E APPLICATION FOR SANITATION PERMIT ........ 1..................................... {Complete In Triplicate) _ _ . _ Permit Na. .7�`37�' ................... =• ............. ...... This Permit Expires t Year from Date Issued Date Issued _ .141/ 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 Ordinancend existing Rules and Regulations: JOB ADDR>SS/LOCATION . .!� .. ...1 -- ... •• -----.CEtVSUS T Owner's Name `�S -Y - -l-�-s-C�r� r^-.. ' ----•-•---• � /-_..�� .• ... Phone Address _.._ _ ��_-- y •---1 ................ .. ..__.. ,�1�4 ... ... ....... ._.. city Contractor's Name License __.......... Phone Installation will serve: Residence WApartment House] Commercial oTrailer Court 0 Motel❑Other----••-------•-•............................ 7 Number of living units:-.-.f.__..._ Number of bedrooms Garbage Grinder .•. Lot Size _. .._ ----•-- Water Supply: Public System and name .............. ......Private Character of soil to a depth of 3 feet: Sand 0 Silt 0 Gay [I Peat C] Sandy Loam D Clay Loam gq� � Hardpan & Adobe E�_ Fill Mcteriai ............ If yes,type............... ............ (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 pyblic .ewer Is ayailoble within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f 1 Size_. . .•f { . Liquid Depth . f capacity d � ' Material. pe --- No. Compartments Distance.to nearest: Well _t7._.B_ Foundation r ----------------------- - at�— --1. _..._..._.. Prop. Una _p........... 00 LEACHING LINE No. of lines . ...___.. g ---- Length of each line.... ...................... Total len th ......... Q.._.........rn 'D' Box Type Filter Material ,$=.�.._ -= ••_-- - ...Depth .Filter Material .....�. ........... r ; Distance to nearest. Well ... -.a.11...... .. - .� .. Fo ndation ---- -.�...---_--- Property line ..�:�-P....... 1 SEEPAGE Depth ._s ------ iDiameter Z.5__.___. Number �........ V. Rock Filled Yes No 0......... Vp - r Water Table Depth " P ""'�� Rock Size ' Distance to nearest. Well 1.��_'� •s Prop, line CJ .Foundation .._. .... REPAIR/ADDITION(Prev. Sanitation Permit# .............................................. Date ................................... ) Septic Tank (Specify Requirements) . ---•........................... . .....•------•-•-•------....------......._....._..._ , Disposal Field (Specify Requirements) ............----------------------------------------------------- -------------------------------------------- I - -----------------------------•---------------• • ---------------•-•--•------------.._...------- .................. -------- ...................... ............. .................. (Draw existing and required addition on reverse side) f I hereby certify that l 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 Heal&District. Home owner or licen- sed agents signature certifies tate 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 f as to becat a sublet to Workman's Compe sation laws California.," Signed ----- ... `-=---•76 ---------- --- ---- ------ --- Ciwncr BY •------_...--•---------------- ---- Tittle . ------- -`. (If other than owner) ------ -------- ---------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ BUILDINGPERMIT ISSUED ------------------------ - -------------------------------------- ..................... ------DATE ......_._ ...................... ADDITIONAL COMMENTS ---------------- -------------------------------------------•...... -----•-- ---- -=------- -----.....----.. --------I.------------------ --------- ---------_-------------- .........................-- -------------- ------------------ --- ------ Final inspection by .......................Date .. ...r---- •_. ...._. EH 13 2h 1-6v• SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 r