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FOR OFFICE USE- .. } ..................•_....__.._.....__'__....' APPLICATION ICOR SANITATION PERMIT } r (Complete In Triplicate) Permit No. . _...-•-•.............................. ............... This Permit Expires if Year From Da#i Issued Date Issued s -/ Application is hereby made to the San Joaquin 10 al Health District for a permit to construct and Install the work herein described. This application is mails in complies ce•with County O inance No. 549 and existing Rules and Regulations: gg JOB ADDRESS/LOCATION ...... . . ................ ... CENSUS T --- ............................ Owner's Name -•---....---�---- _ ...... ................... Address •....... ..............................Phone . Ity • ----... -•----....-•....................Contractor's Name - -- ----- -- License ..•-•-(-p---G---,... ---- � -It Phone Installation will serve. Residence Apartment House fl Commercial;❑Trailer Court 0 Motel ❑Other......... Number of living units:-..--/ Number of bedrooms Garbage Grinder Lot Size �Mo. �- Water Supply: Public System and name _:..---•-- -......._............................ . I PrivatSande Character of sail to a depth of 3 feet: Sand❑ Silt a Clay ❑ Peat❑ y Loam 0 Clay Loam Hardpan ❑ Adobe Fill Materlal _..__.......if yes,type............... ... (Plot pian, showing size of "lot, location of system In relation to wells, buildings, etc. must be placedfon reverse side.) NEW INSTALLATION.—(No-septic-tank-or-seepage-pit Permitted-if=public-sewer is available within 200 feet,} PACIGAGE TREATMENT ( J SEPTIC TANKt ' IC ) Size.. .---X.................-... Culuic j Depth CapacityType Material... compartmentsN -�; 9 Distance. to nearest: Well Foundation__,___._.,, ,-._P_r_op._Une . ....... - LEAGHING,�INE ) No. of Lines _..--.--•-----= jee gth of each fine........ .... ...•---•-----. Total length y.......-------...---...._...1h Sox .... ------. Type Filter Material •-------------Dept Filter'Ahatetial ..- Distance to nearest: Well__._... �-------------- Foundation -=-...-•-:-•.............P operty Line ....................... SEEPAGE PIT { j Depth ..- , _-- Diameter a. ---------- -------- --- Number ...............: \.:-,rock Filled Yea ❑ No ID i Water Table DepthRock'Size -�. ---•--l---• •---•• -• i Distance to nearest: Weld.._..._._- .. ' -••--(---------------------Foundation ----......n........ Prop. line 11 REPAIR/ADDITION(Prev. Sanitation Permity ...`l-__..-*. :,_ ` ---••_•__ ' 4r�,, , Y Date --- 4 s .. } Septic Tank {Specify Requirements) _• ............................ 4 Disposal Field (Specify Requirements) ---.-_..__- -- - _............ .................. - _. . j �(J 1• ------------ -------•------- + 3 C w F -------•---•----•-• ...:: ...h (Draw existing and-required addition on reverse side) ' I hereby certify that 1 have prepared this aPplication and nkat-the iW6&c will;-b6 don in ctccordpnci>with San Joaquin County Ordinances, State Laws, and Rules and RegulaiionsYof the San Joaquin Local Health`bistrict. Home owner or licen- sed agents signature certifies the following: i "! certify that in the perfortnance of the work for which this :permit is issued, I skal of 0"Jilay army. erson in such manner as to beciome�subject to Workman's Compensation laws of California." Signed -- [ - ---• - `_- ---•-- Owner � BYE --, --.--- -+• is - _ .. .... . . Yi 17 (if of e than owner! �,, `; -�� - --•--.- ---------F................ r /FO DEPARTMENT USE ONLY APPLICATION ACCEPTED_ BUILDING PERMIT" ISSUED ----------------- ^.` � _._�...__.-�� DATE .�. ADDITIONAL COMMENTS ------- __�, ©ATE -......... t '. .: :,. ; ---------------- ----------�' - :---- �.. -------- � _... . ------ ----------- ......................................................... ------------------- •"""-......--_--- 1 . Final Inspection b 14 °:---:`:. ._ ...- EH -13 24 1-68 Rev. aAi � �, . .. -------••...... .......gate ...... SAN JOAQUIN;LOCAL HEALTH DISTRICT 1/7h 3M _ i