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FOR OFFICE USE: ;,APPLICATION FOR SANITATION PERMIT --'-G --------- --- ------ Permit No. W 2 _ e (ComAlete in Triplicate) :. r=------------ �. �� : Date Issued -3a-7v _---------------------------__--------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the'Sa Joaquin Local Health District for a permit to construct and install the work herein described. T is,an2lication i ade E c pliancy i Count O ance No. 549 and existing Rules and R u�ions: I JOB ADDIESS/LOCATION .� _-_/ - , f - t - ---- . -�C� �--�- '-CE SU i } a Owner's Name �4.---- t ' 1 �oa GX��c.�c-.� City-- i P -------=Address / ! Contractor's Name --------P`) ------ = License # ` '�-drone - Installation will serve: Residence partment 14o6 e�❑ Commercial :❑Trailer Court i❑ w r= Motel ❑Other --------- --------------------------------- (� Number of living units:---/------ Number of bedroomsC�___Garbage Grinder ------------ Lot Size 1.4t '___-_"-- ---------------- Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private ' Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay ❑ Peat❑ Sandy Loam ,E] Clay Loam:❑ Hardpan E] 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 septic tank or seepage ee a e Pit permitted if public is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK: I - Liquid Depth - _-.-..-- Materia ____ . �L 1r____ o. Co artments _ '...___.. Capacity ------- Type --- � P Distance t'o nearest: Well _c a ________________Foundation ____.jQ__�__,'__ Prop. Line ___ _�_________ LEACHING LINE No, of Lines____ ---------------- Length of each line- _a Total Length :__ __�. -�_________- 'D' Box _ __ Type Filter Materialie _'-------Depth Filter Material _/d r Distant to nearest: Well p7Do-------- Foundation _ ____-______ Property Line. _j _____________ SEEPAGE PIT [},� Depth' -- ------- Diameter _. _ _______ Number _______._�___ _�____---_ Rock Filled Yes No .i❑ i Water Table Depth -----------V t------ -------------------Rock Size 2 ---- ------------ _ Distance to nearest: Well /•`______________,_•._Foundation ____ _Q:_i_____ Prop. Line _a -_______r_. ' l , REPAIR./ADDITION(Prev. Sanitation Permit# -----------------_-----------------.___--__ Date ------------------- ------------ Septic Tank (Specify Requirements) .----------------------------------- . ----------------------------------- ------------------------ ----------- Disposal Field (Specify Requirements) _ * ' ----------------- -- --------- --.-;;------- --------------------_---------------------- ----- - i ; ------------------------------------------------=------ ---- ------------- -------------------------- ----------=--------------------------------------------------------------------------------- - - ________ --------------- --- --- -- -----~----------------`----------------------- ------ (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 'L'aws,-and Rules arrd Regulations of the San Joaquin Local Health District. Homeowner or licen- sed agents signature certifies the following: o /� "I certify that in the performance of the work.-for which this permit is issued, I stroll not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --------------- - ---------------------- ------ -- ---- ---'f-------------------------------- Owner-------- . . 6 --- -- Title ------- - -- (If of -r than owner) FOR .DEPARTM115N73USE"'ONLY. f , ; jDATE ------ APPLICATION ACCEPTED ------------------------------------------- BUILDING TIS - _ - -w ----- - - ---------------------- DATE ADDITIONAL COMMENTS --------.__1---------------- ------ r '---- =,------------ ;- ------------------------------------------------------------ --- ------ - ---------------------------------------------- ----------------- f = - - ------------------------ - - --- ------------- - ------------- -- ------------- --- -- Final Inspection by: - ------------------------Date . 'Y,• � d SAN J C ALT ISTRICT (� I E. H.-9.. 1-'68 Rev. 5M. .•, ,'_ '� �.. L -;fi