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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7 4......................................................... (Complete in Triplicate) Permit No. ------------------------------------------ - This Permit Expires 1 Year From Date Issued Date Issued . 17 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 and existing Rules and Regulations. JOB ADDRESS/LOCA ION ......- " .....A�e------------------------------ -----------------------------------CENSUS TRACT .......................... Owner's Name / �'� -------•. .................................................................Phone .................................... I'€ Address -- .... .` ..0 -I -- ----- ---- ............... ........ City .....................................I.............. ... ..... 7-1 ` Contractor's Name '- License # ,�� Phone o ... r . Installation will serve: Residence 'Apartment House❑ Commercial [-]Trailer Court Motel Other ........................................... Number of living units:---- ..-... Number of dr oms . ..Garbage Grinder .. Lot Size ... Water Supply: Public System and name . 710,y-- --- .................................Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ ❑ Peat❑ Sandy Loam ❑ Clay Loam 1. Hardpan EJAdobe-[3Fill Material ............ If yes,type ............................ NZ i {Plot plan, showing size of lot, location of. system in relation to wells, buildings, etcmust 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-[ ] Size.......... ..................................... Liquid Depth ------------•----.-.------ Capacity -------------- ..... Type ..__..__.....-_. ... Material--------------.... No. Compartments Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE ( ] No. of lines ------,--------------- Length of each line.-....A-0............. Total Length ..V.e............... D' Box Type Filter Material ......Depth Filter Materia! . Distance to nearest: Well ........................ Foundation ./&5............... Property Line .5.................. zaa&q&-RFr ( j Depthc0._A-10A/Rimeter ............... Number ........../. Rock Filled Yes.] No ❑ Water Table Depth _.......--•---......--•••--•....................Rock Size .....,... ................ Distance to nearest: Well ........................................Foundation ..... ....... I..... Prop. Line ...................... REPAIR/ADDITION{Prev. Sanitation Permit# ............................................ Date ..................................I iSeptic Tank (Specify Requirements) ......................................................._.................................................................................. DisposalField (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 done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or licew sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman' pensation laws of California." Signed "oth - --• - - -- --- ----- -..................... ------------ ------------- Owner By .._.... `' G . title . ............... ............................................-------- than own ri P R DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY -e-. -P ..... f`�-T d DATE . ......71r.�. BUILDING PERMIT ISSUED ---------------------------------------- -•--••-•. ... .----------------------------------------------------DATE ................................... ....... ADDITIONALCOMMENTS ...-.._ ------------------•---------_............--•---.......-•---•---•-• ...................... •-•.................... .... .. .. ....... ......I..••••-• .....................-................................................................................................ ... Final Inspection b .... . ... .. ..... ..............Date ...... .�- ... A y ,7�............. lj AN JOAQUJN EOCAL HEALTH DISTRICT co 13 24 E. H. 1.'68 Rev. 5M 7/72 3 M