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FOR Of FICE USE. APPLICA'T'ION FOR SANITATION PERMIT [ a (Complete in Triplicate) Permit No. ........... ................... 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 with County Ordinance No. 549 and existing Rules and Regulations: I � F JOB ADDRESS/LOCATION ......... 1. ...... ...... . ......-..-..CENSUS TRACT ....... .................. Owner's Name ........ff1. . F._.... Phone ... Address .....-. _/' Q ---------------- City ................ ............................ Contractor's Name license # �lFr... Phare , T •. .�... Installation will serve: Residence Apartment House-E] Commercial ❑Trailer Court ;❑ i Motel ❑Other ....................... ----- / Number of living units:....... Number of b roams ._�-------Ga ba a Grinder �'. lot Size 1• U��_: ...�...:... �.. ` I Water Supp ..Supply: Public System`and name . .___Ca! •%.9-�................................................... ..........Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam n V Hardpan ❑ 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.) g NEW INSTALLATION: (No septic tank or seepage pit permitted if public.sewer is available within 200 feet,) 1 PACKAGE� TREATMENT [ ] SEPTIC TANK i 12*rS'77 ize..:................__•.--.--.--.:..........!-. Liquid Depth ............. Capacity _ _ . Type .................... Material_: ........... ....... No. Compartments ------------------•-•- Distance to nearest: Well . - ..._.....__.......................Foundation ......... ............ Prop. Line ............ LEACHING LINE [ No. of Lines Length of each line ...... .... Total length . 4� ................ / 'D' Box .-�j�. Type Filter Material Depth Filter Material _1.�_sr_______________________________ i Distance to nearest: Weil .� Foundation .... --t.._...... Property Line .........:....... Depth . lam. ....-._. Diameter4/.�.rfs'1r_-. Number .............. Rock Filled Yes ` No ❑ i AZ4 -� Water Table Depth ----------------------------Rock Size .... ..-.-..----. --... .- r f .. - •-- I Distance to nearest: Well _... --A� _4< �1..__.._..Foundation _�p Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ..:.. ........•.•.-_-.---.---.......-_._.._. Date ------------------_-------__l Septic Tank (Specify Requirements) ........ ....... .. { ---------•-•---................ ..... _. -- ---------------------------------------------------- - Disposal Field (Specify Requirements) .. �-- ......--•----- ........ .......... .................................. ..."". .... - ....... .- ..... ---- - --............... .... ..... ................. .. t. • ..N ., (Draw existing and required nddi'tion on reverse.side) r 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. Home owner or iicen- 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 r . k By .._: °. _ . L . ---- ------------- --- Title ......................... : . (If other than owner) F R DEPA TMENT USE ONLY APPLICATION ACCEPTED BY ...._ .._ .............. DATE 1.a�...`: .`7--- -•--... BUILDING PERMIT ISSUED .... ... . .........-- .. . . DATE - ........._. .............. ADDITIONAL COMMENTS ................... .... ----------- ........-----------•------------------- ..................... ............. ..........----------------- ----------------- ---------_._-----------. ---......LL------L.......j.............. .................------- ---------------------------------------------------------------------- ...... Final Inspection by: ..--.-.... ----Date --. .. ..:j .. .,_...• 5AN IOAQ.UIN LOCAL HEALTH DISTRICT E. H_ 13 241.'68 Rev. 5M _ 1