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FOR OFFICE USE: t APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit o. 1 Date Issued ---------- /-------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joa uin Local Health District for a permit to construct and install the work herein PP Y q described. This application is made in compliance with Co my, Or inprice No. 549 and existing Rules and Regulations: f✓ l JOB ADDRESS/LOCATION . - ---- F --------------------CENSUS TRACT --------- Owner's Name j� t Z ) --------------------- ----Phone ---------------------------- Address ------------------------- 40, A(S ` 7- Contractor's Name .../, _ _..__lC �_� ------------------------------------ ____ __.License # G'- - '�Phone .!_.--- _ � Installation will serve: Residence ' partment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------- ---- / Number of living units:--- Number of dro Ts ___Garba a Grinder ..__ Lot Size - --------- --------------- "7 ------------ j Water Supply: Public System and name __. U�Q._I_ ____F____u✓ rt__., % .._______________________________________Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay P_ ."Peat❑] Sandy Loam ❑ Clay Loam ;❑ r Hardpan E] ^ Adobe ill Material P__ 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 public sewer is available within 200 feet,)�// .� PACKAGE TREATMENT [ ] SEPTIC TANK[ e_...' -_______________ Liquid Depth -.= Z,:..._...._. G : Capacity _,�_ _____,__ Type Awd-_A'Watericil _/_144PZONo. Compartments ... V+ Distance to nearest: Well -------------- ___--_____ _ Foundation ------- Prop. Line LEACHING LINE No. of Lines _ 17 _____I_______________ Length of epch line--/ _0____________ Total Length ........... q ar ,� Z __-_De Depth Filter Material _..__.__. D' Box __ �j�C Type Filter Material __ _� .. p __--__-___ _ (o Distance to nearest: Well -------__--------------- Foundation ---flelf----------- Property Line ........................ SEEPAGE PIT �) Depth ---------- Diameter _-- Number -------.-/----------------- Rock Filled Yes lj��o i❑ ro Water Table Depth -------- - --------------------------------Rock Size -------- Distance to nearest: Well ---------------,77=_.....Foundation ----- Prop. Line ^/.-------. REPAIR/ADDITION(Prev. Sanitation Permit# _.� �_____�_ __ _____________ Date SepticTank (Specify Requirements) _._---------------------------------------------------------------------------------------------------------«.--------------------------- Disposal Field (Specify Requirements) _--_-__-__ _____________________----------- ------------------------------------------------ ------------------------------------------------------------------------------------- _-_-__-__---------------------------------------------------------------------------------------------------------------------------------- ------------------------ ----------------------------------------- --------------- ------------------------- - ------ - ------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 111 I hereby certify that I have prepared this application and that the work will be done in accordance with Saa 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 ------------ ----- --------------t-=---------------------------- --------------------- Owner ( D By ------------------- ---------- �`��IL. --------------------- Title ----- __/f'_L,�-Y� - ----------------- -------------------------- (If oth an 3wner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -----171R4----- --------------------- -------------------------- DATE ..../--- ---- BUILDING -BUILDING PERMIT ISSUED ---------------- -------DATE - .---------------- ----------------------- ------------------------------------------------------------------ ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------- ----------------------------------------- ----------------------- -s - _-___ _ _ _ ____ ,� _ ______________________________ _____________ ____________________ _______ ________________________________________________________ ------------ ----------- - ----- -- - -------------- -- ------ - - -- ------ -- - - -- Final Inspection bY: Date Vim✓ SAN" JO QUIN LOCAL HEALTH DISTRICT '"�> E. H. 9 1-'68 Rev. 5M C-