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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit (Complete in Triplicate) . .............. - Date Issued .3.' -7..3 This Permit Expires 1 Year From 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 with County Ordinance No. 549 and existing Rules and Regulations, JOB ADDRESS/LOCATION CENSUS TRACT .��..y.�-... !G�. 1 `... .+.-.. ,.w . ..: �... .....f _ ......... ......Phone .................................... Owner's Name If Address `... ...�x.�..r.1t�'•s�•_ .J•--.... ....►.:7....City ........ . Contractor's Name ,4r r�-ti.-� y ��.' '"� . -�.F`-.'-` .-.'v°-1'License Installation will serve: Residence❑vApartment House/❑ Commercial []Trailer Court ❑ 1 Motel ❑Other a Number of living unitr. ... ....... Number of bedrooms ...Y.....Garbage Grinder ... ..... .. lot Size ... 's Water Supply: Public System and name Private . . Character of soil to a deprh of 3 feet: Sand[] Silt❑ Clay ❑ Peat❑ Sandy loam Clay Loam ❑ t 4 Hardpor [] Adobe E] Fill Material ............If yes,type............................ a (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 �f public sewer is available within 200 feet,) , O PACKAGE TREATMENT [ ] SEPTIC TANK Size/.`aZ.. -- 7 /Y.9.... r.................. liquid Depth .. .......•••........ Capacity � C?.:! Type V. c I . Material...Ct-+�"`�''--... No. Compartments ..�. .'.-...i...... ' e r Foundation ..... .. Prop. line......>r?........... Distance to nearest/ Well .. ... ...,�� si............. � LEACHING LINE [ J No. of Lines Length of each line ..... ,5 Q....- .. . . Total length ..Y. .............. � - - -- - . c D Depth Filter Material ...�Ir.. r........ 'D' Box Type Filter Material ..c.7..!1 ""' r } i Distance to nearest: Well ... ... x.........11 Foundation .....h ............ Property Line .... ............... s t / x Numbs• ........./........ ...... Rock Filled Yes No Q Depth .....r_ir......... er , ' Water Table Depth ..............7.G'. ........................Rock Size .. .. ...r..,.�..�1' s ' .......... C Distance to nearest: Well ........�ni p....................Foundatlon ...1�-•-••• • �oP• Line ...5._. .......... Date ..................................) REPAIR/ADDITION(Prev. Sanitation Permit# ................................. . ............... Septic Tank (Specify Requirements) _ ........... ....................................................................... _. t, .................................. Disposal Field (Specify Requirements) ................................................................................... ............... 6 .......................................................................................... x : -' ....................................... .j ............. (Draw existing and required addition on reverse side) n and that the work will be done In accordance with San Jeaquln <t. County Ordinances, State Laws, and Rules and Regulations a, the Snn Joaquin local Health District. Home owner Of licen- I hereby certify that I have prepared this applicatio 1. 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 Workman's Compensation laws of California:' Signed ... ..... ..... ........ . ......._. ,...�............. Owner N ' .............................. B ....................................-�. .1.'!Ca"�r1 %,..I .' zi►.;,i..... Jftle ..yr,P�s.�!Fw► 1-............ t+ y (If other than owner) O FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY M:'2t,'1 ......................................................... DATE .►3..'. �. a . ..................DATE .................. ...................... . BUILDING PERMIT ISSUED . ................ ) [J ADDITIONAL COMMENTS .— _. _ ....................................... ....................................................................................................... ............... 9 ........ ....... _. ... _.......... .......................................... .. ..................................... .. .,. ................................................_....................................... ..................................... ' _ .Date�.." 3.......... ......... Final Inspection by: . ... �. ��'�!�!��................................ ......._...... . ............. i SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1•'68 Rev. 5M '1