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---POR OFFICE USE'v APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) �- Permit No: d___ 3f = This Permit Expires 1 Year Pram bate Issued Date Issued _7-'"_�11-470 Application is hereby made to the Son 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/LOCATION .____,( , _��' - 1""cS'l�- J n roX.'ll�rJ-r CENSUS TRACT -------------------------- m sZ" O f yy$yGy� d Pw tk G t o &'�wde Owner's Name •1�V_rA- C xdvl, ._Phone _77 Address ---------- city�y - ! �- -----'��-/-- -------- - - - _ �'-�--- - - "� -----Gla_/�•------ ----------- Contractor's Name -------------------- _W ^--------------------------------------License # Phone Installation will serve: Residence ❑ Apartment House❑ Commercial []Trailer Court ,❑ Motel ❑Other------- Q ��'; Number of living units:_-'"____ Number of bedrooms _ Garbage Grinder _._ _._ Lot Size _._1`Z_� -�a <............. Water Supply: Public System and name -----------____- ------------------•----- ---------- ----- _ e - - ------------------------------------------------ Privat - Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ t Peat❑ Sandy Loam -❑ Clay Loam I Hardpan (] Adobe ❑ Fill Material ------------ 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 septicltank or seepage pit permitted iLpublic-sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK Size_-_ !� o --- - -- --X ----------------- Liquid Depth ----4l__-411----_-- Capacity -- __-- 1 ------ Type _ _RC_G�R'S�Material-�d_A_lNo. Compartments --- ------------- Distance to nearest: Well ____ ter 4----------------__Foundation "_�CJ_._.__---___ pro __ LEACHING LINE [ ] No, of Lines - ------- p Line �� Length of each fine------------- ---- -- ----- Total Length � 1 'D' Box __ _. -- Type Filter Material ---- � _Depth Filter Material If------ { Distance to nearest: Well `_j U�____ Foundation _______________________ Property Line SEEPAGE PIT [ j Depth ...,�- Diameter _______ ___ Number ----- ---------- Rock Filled Yes ❑ No ❑ Water Table Depth ------------------------ -------:Rock Size Distance to nearest: Well __________________________ ___________Foundation __._. Prop. Line _-_____._..____--____ --------------- REPAIR/ADDITION(Prev. Sanitation�Permit C# -------- ----------------------------------- Date ----_--------------_-- ) � Septic Tank (Specify Requirements) ----------------___-,_______________-- ---------------------- Disposal Field (Specify Requirements) _______ ------- ------------ 1I--------------- --------------- ------------ ------- --------------------------------------------------=-------------- {(Draw.existing and required addition on reverse-_side) I hereby certify that I have prepared this application and that the work will a done in accordance 'with San Joaqu n� 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: y{ "I certify that in the performance of the work for which this permit is issued, I shall not employ { as to beco a subje t to Work an's' mpensat<on laws o alifornia." p y an Y person in such manner 1 Signed _ -- --------------- Owner. � - - - -- ----- -- - - BY ------ Title _ y - -- -- ------ (if other than o DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ _______ _.-----___--_- -- -_:- ; BUILDING PERMIT ISSUED ---------------- -----:-- - - ---------------------------------- DATE ---1 J 7 ADDITIONAL COMMENTS ______________.............................................. ---------------------------------DATE _------------------------------------------------------------------------------------ ------------------------------------- ------------ ---------------------------------------------------------------------- Final inspection by: ----- -- ---------------------------------------Date ---- _- ' - - - ---------- N JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ~