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1 r FOR OFFICE USE; 4PPLICATION FOR SANITATION PENT !Complete in Triplicate} Permit-No. __�- _ __.____ ----------------------------- ------------------------ This Permit Expires 1 Year From bate Issued Date Issued Z�--------7 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install .the work herein F described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION Pa_Y_.(_1_,n-----Fait7mx_..4 Q_ s_-_ Y____ _CENSUS TRACT Owner's Name __-- ----L.-�-�-15__-_--- --� ---------------- - --- Phone ------------------ Address ...�-3--7�-�-- --- �r--- �=:rr � ----------------- ---------- qq - - --------------------------- City ---- Ll_ /----------------7:5 Contractor's Name _.. L�-�lj?_C �1-,�Q $ / a 1 ic-il------------------------- # f2 Phone ---- Installation will serve: Residence RD-Al5artment House-C] Commercial L]Trailer Court E] f Motel ❑ Other ----------------------- _----- Number of living units-----! ----- Number of bedrooms __ ----Garba a Grinder ------------ Lot Size ------------------------- --- Water Supply: Public System and name --------------------------------- -------- --- Private — �•---�Je• --,--L.-- --------------------------------------------- Character of soil to a depth of 3 feet: Sand []' Sift.] Clay mat �r -E] andy Loam .E] Clay Loom.0 I Hardpan P gq---Adobe C] Fill Material ------------ If yes.type ---------------------------- � � I k (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 pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT . [ ] SEPTIC-TANK: �,� sE <�..:.:.� a-1--------------------- Liquid Depth _.-�0------- E ] size--- -�--� --- r-a Capacity,j�POf' 7 e :. ' ---- �Et�ssMaterial----------------------- No. Compartments --- ---------=---- f R t Distance to nearest: Well d ' Foundation Prop. Line --- .-------------- LEACHING LINE [ ] No. of Lines -- -.____:=__ L6ngth of each line_,____ -.------__--- Total Length r -(3 1 ---- - ----- D' Box --j____-- Type Filter Mdt' al j-1---MC4Depth Filter Material -----f-C3--------.------ Distance to nearest: Well ._:_ D� ,__ Fouhdation--___1 --------._------- Property Line __ __ -__,_____- SEEPAGE PIT [ ) Depth _- _S_-_.... piameter _-->� __y_. Number ---------�-___--____i_.�Rock Filled Yes ] No Water Table Depth --------------- _Q 0.-------•------...Rock Size ------I 'z -- --- Distance to nearest: Well ------1__o i--------------•__Foundation _?_ ___ Prop. Line 1 t REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- i ' Date -------••-------------------------} Septic Tank (Specify Requirements) ----------------------------------------- Disposal _______-___________________ __Disposal Field (Specify Requirements) -----------_ ---------•-------- ---- I - -------------------------------- --------------- (Draw existing and required addition on reverse side) J 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 t as to become subject to Workman's Compensation laws of California." Signed ------- ---- --------------------- --- --------- - -------------------------------------- Owner 4 BY ------- ----------------------- Title other than owner) -, FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - .__ _ __.�.�✓'-c� _-____ ' DATE. a f` - 3----------- BUILDING PERMIT ISSUED --------------- -- - ------ -------------- -------------- -----------------• - 4i _ ADDITIONAL COMMENTS _ __ --------------------------------------------------------------------------=--------------DA ----------. . 1 - ------------------------------------------ --------------•- fes,.. .-r_ ., �_ r'= . --------------- ------ r. -------------------------------------------------------- --------------- �°'-^f�--------------------- --------------------------------------- ------------------ _ _ Final Inspection b --- - � -- ------------- ------------------ -----�- -:�- z Date -------------- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT` E. H. 9 1-'68 Rev. 5M