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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ...� al .............................................. This Permit Expires Year From Date Issued Date Issued Application is hereby made to'the San Joaquin Loral Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: JOB ADDRESS LOCATION .. ._,? .�. Q.Cca:C;:� -.. ADDRESS/LOCATION � .. _ ._ _ ..........................CENSUS TRACT ..................._...... Owner's Name .........1.?f.Y----- --QCA..Cr�`h/��._�'. `�f..................... ... ..........f' .. ......-----•------Phone,��$-..�•��....... .7 Address ... .1 .. ' 60. .-- - �f-P l — ....................... City ...--Cum bare!a414i.......................................... Contractor's Name ......b..Iq:... tf► ---- .. ..................License # -_- Phone Installation will serve: Residence [Apartment House Commercial ❑Trailer Court ❑ ' Motel ❑Other ............................................. Number of living units:.___.r:.:: Number of ,bedrooms .. ?......Garbage Grinder ............ Lot Size ...� ............. Water Supply: Public System and name ..--••-•-•------------••-............ ......... .....Private ...._.�_._...._ .�,..:_.. ._ Character of soil to a depth of 3 feet: Sand 0. . Slit❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam +A °Htsrd)$on [ AdWo-31IMF I Material .... If yes, type .......................... -• 1, (Plot plan, snowing size of lot, location of. system-in_relatio.n to-wells„buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if pu lic sewer is avail blP within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK. Sise._,.?r_ _ x X_�'`....�5�_.__ Liquid Deptl, ..S.S� /i........ ? .3 Capacity . ) `Type I --- G--- -�'_ Material._. s.Y No. Compartments .�,................ h '= Distance to nearest: Well __ � Foundation Prop. '; ndat� tine .,.: -- I �. i LEACHING LINE No. of Lines 4....:I-.,.3 . Length of each line.................... Total Length A .C�............... 0 i 'D' Box ....._._.. Type Filter MateriAl A ........Depth Filter Material ../ -•............I.................... r � t ' r rLA Distance to nearest: Weil;...w] _... ........ Foundation _..Jt�...........:... Property Line ................ SEEPAGE PIT ( Depth ..p�... ....... DIoTeteo ...... Number .... .._ .... Rock Filled Yes, No {] Water I,Toble Depth U 'f .....Rock Size J fz- .. Distance'to�nearest:`Well 'Y' 4 .:. ............... Foundation _ b...._......._ Pro Line ,f p. REPAIR/ADDITION(Prev. Sanitation Permit# ....................•....................... Date .................................. V ' SepticTank (Specify Requirements) ...-•---------------•---.....---•-----•-----------------------•------------.....................................----- ._............----- DisposalField (Specify Requirements) ---•---••--•-------•-------- •-----•-•••-•-••----•---•-•--•........................................................................ i r .... . - ..... ....... ...........................•-•---------- --•-- --- ..._................... .....---.. _ ... ............................... ............................................................. !i (Draw existing and required addition on reverse side) I 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. Nome 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 Work 's Compensation laws of California... Signed ... ........................ ............ .................. By ................. -----............... . Title ..........._........ ( f other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..................................................................................................... DATE BUILDING PERMIT ISSUED/4nl --- -•_. �......: .:. .......DATE .... ........ ADDITIONAL COMMENTS .......-•--•...........................................:........ .............� 7.. ..7 1:-•----- � - _ :_. . .._... r .. .............. ...................................................................................................... ................... ....... ...._.............. ...... ... __.... . --------•-•------- Final Inspection by .........�. ...................•-•-••----------------------------------•• - ......-•-•----...----•--.._..-•----.Date _._._ -7 .. __..._............... . SAN JOAQUIN -LOCAL' HEALTH DISTRICT UL E. H.13 24 1-'68 Rev. 5M 7/723-114