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FOR OFFICE USE: APPLICAT{ON FOR SANl7ATION PERMIT Permit No. ..7............... ................... iCom lets in Triplicate) Date issued .............. .................... .............•-•---...._.....I....._..._.._..._..... This Permit Expires '1 Year From Date Issue 1 Application is hereby made to the San Joaquin Local Health District fora permit to construct and instol! the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: CE NSU5 TRACT Z .Z ... JOB ADDRESS/LOCATION y .......... Phone ---•-..--••. ................••-- _ . Owner's Namer�. .. /I ... Address .............. - ..c?License Contractor's Name ...._. # � sh_? .... Phone ... L .�-�••�•� ----•- i Installation will serve: Residence Apartment House Commercial ❑Trailer Court C3 Motel ❑Other ............... ............................ r Garbo a Grinder ------------ Lot Size ......�--- =,r� .._.... Number-of living units:.._--- Number of bedrooms __. ..-_-••- g _ _ Y rivate ❑' ' ._.._Y ...... -- Water Supply: Public System and name --.. ------------ ---- -- - - Peat[] Sandy Loam 0 Clay Loam ❑ Character of'.soil nto a depth of 3 feet: Sand O Silt❑ Clay a0 Fill Material:. if yes.type ;: :.... Hardpan ❑ Adobe ❑ f on {Plot plan, showing size of lot, location of..system in relation to wells, buildings, etc. musWbharP�aodeet,) reverse side.) f .__ NEW INSTALLATIONc"(No=septic-ta yk-orTseepag�t permitted if public sewer.is available Liquid Depth .-----.......•........... � -- PACKAGE TREATMENT [ ] SEPTIC TALK t ] . Type ._-_----•---- .. ._ Material----...-----•----- ---• No. Compartments ...................... � Capacity ..._..--•--••----- Yp Distance to nearest.• Well ................................... -•- Prop. Line ................... . LEACHING LINE [ l ---- Length of each line.---•--- •-----••: .._ Total Length __... ......_. Na. of Lines - .De Depth Filter Material .--••-..-_...-•-••-••--.....--••••.......... i 'D' Box .---�-..._._ Type'Filter Material _..:.:----- ....... P Line ._._ Foundation ....__...---•-•-- Property ...--••-•---••-•---•-... Distance to nearest: Well .................... No �❑ Depth Diameter -------------•-- Number -- ................... Rock Filled Yes ❑ SEEPAGE PIT [ � p � a ,__,....__..Rock Size -- . -- ---- Distance to nearest: Well ...... ......................Water Table Depth -------- ------------------------ -•-•-• Prop. ane --------------•-- - Date ' REPAIR/ADDITION(Prev. Sanitation Permit# -•.-----••• -------------------------------- -� ... a - ---- �_...__...... /__ ---- Septic Tank (Specify Requirements) _....---••_. ..._ . - :..................•-- ... ...- r _ _ - - ,�_ ... .. _ � . ' Disposal-Field�{Specify Reguiremen#sl — ............... r1_ --------- ---------1.42 . _ r� L — ` f - � ----------- Ff - __ --------- (Draw existing d required addition on reverse side) 1. 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. Horne owner or liten- sod agents signature certifies the'following: ermit is issued, l shall not employ any parson in such manner "I certify that in the performance of the work for which this p as to become subject to.Workman's Co ansation laws of California." . - Owner Signed ... ✓t ...................... - . __.._..:----•• -- ...--- C!�.. Title _.- ------•• .. ......... ...... .... / i By (If other than owner FOR DEPARTMENT USE PNLY r x DATE . ........ .... ............. •-•-• �. DATE APPLICATION ACCEPTED BY •------7.. BUII,PING PERMIT ISSUED =ADDITIONAL COMMENTS ................ - - .......................... ?- - .....---•- --------------- - --• --- - • . :....._ - y ... ` .... ..... Date --•----- 1 Inspection b : • P Fina Y SAN JOAQU LOCAL HEALTH DISTRICT Ute' l ' 7/72 3 M 1 O 11 It - _ _ .. m a l -