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FOR OFFICE usl=: APPLICATION FOR SANITATION PERMIT j -------------- Permit No. __71-- 3f.6 ti (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Date Issued ` 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 wiithh County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ._-._ /__ �- -------_.N7 ----- 'i'. ----- '--------------CENSUS TRACT -------------------------- Owner's Name -------------u--��D - --- --- -- - ----------- - ------------Phone - ----AddressD � � Ci#Y �T•SS� - G-- Contractor`3 Name -------- �0 e-------- � — ___________________License #. X.f77___ Phone � Installation will serve: Residence,[&Apartment House,0 Commercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Number ------------------------------------- --Number of living units:_.--L Number of bedr oms --4o?------ Grinder ------------ Lot Size ___ �x l rS� -------------------------------- Water Supply: Public System and name -------- --------- ^- -----------I.�_��------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.E] Hardpan ❑ Adobe'❑ Fill Material ------------ If yes, type __-------__________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc411�ust be placed on reverse side.) V NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT I ] SEPTIC TANK f ] fir s��`��Size----------------------- ---`-, Liquid Depth ------------------ I Capacity ----------- --- -- Type -------------------- Material No. Compartments Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- :---..--- LEACHING LINE [ '° allo. of Lines ___/______________ Length of each line----- + __r-_--_____ Total Length ,_____ 'o__�.___-_.__ f� 'D' Box ---/_---- Type Filter Material Al------- Filter Material ----/Y------------------------------- r o57 I Distance to nearest: Well ___ `Q____________ Foundation --�4'____..________ Property Line ___ _________________ 01 PIT [ J Depth _ ._r______ Diameter X_ Number ------ /______________ Rock Filled Yes g No 0 i 11 Water Table Depth --- - ----------------------------Rock Size ---- ---��--------------- l Distance to nearest: Well ------�SS_______________________Foundation ----4e�Q-------- Prop. Line ___51 � REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------`-------------------- Date ----------------------------------I a Septic Tank {Specify Requirements) ---- ----------------- ------------ ------------------------------------------------------- -------- ----------------fD------- 1 "4• �y r Disposal Field (Specify Requirements) ----- - ----------7--a ------ ----------------- ------------------------------------ ------- -- ---- ------------ ------- = --------------------------------------------------- ----------------------------------------- -----------------------------------------•;------------------------------------------------------- ------ (Draw existing and required addition on reverse side) 01 I hereby certify that 1 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 licen- sed agents signature certifies the following: I "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 -- Owner „� I Title ----------- i ---------------- BY � .. (If other than owner) • ,iz k TR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ----------- --------------- ---`-------- ------------------------------------ DATE --- .�4 g -71--------------- BUILDING PERMIT ISSUED ----------------------------------------- ----- --DATE ADDITIONALCOMMENTS -------------- ---------------------------------------------------------------------------------------------------- ------------- ---------------------------- -----------------------------------------------------------------------------------------------=---------------------------------------------------------------------------------------------------------- --------------------------------------- ------ - ------------------------------------------------------------------------=----------------------------------------r------------------------------------ ----------------------------- 4� Final Inspection by: --------- .Date -.. ------------------------------- 4 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. C; ,