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I • 1 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --.....-... Permit No. .-75� -- •-..............-_11-1-1............. ............. (Complete in Triplicate) ...................................................... This Permit Expires i Year From Date Issued Hate 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 matte in compliances wwithh County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ...... 10 .... ../..'r'4r ci!`�."'t+ �..................CENSUS TRACT .......................... Owner's Name .....-< 7-�,r ... -. � -------••...........................• Phone ........_...... Address .7J .-.. City Contractor's Name ........ ------ ��-----------.License # Phone .............................. Installation will serve: Residence partment House❑ Commercial oTraller Court 0 Motel ❑Other ----------------------•---••------------ -- Number of living units:....-- ... Number of bedrooms _._.-.Garbage Grinder ............ Lot Size ..-- r- "" --.--.----- Water Supply: Public System and name ................-......--•-....................•-------.-_..............................•-----•-.... ..........Private �.. Character of soil to a depth of 3 feet: Sand Slit[:1Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ 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.) NEW INSTALLATION: (No septic tank or seep ge pit permit fd if public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC ANK 7 Siae_ .�.e .- ,�t...-_...-_-- Liquid Depth _.__ ................ Capacity J ..tP.... t--- Type ..... Material.-- tom..... No. Compartments Wit............... Distance to nearest: Well ........ ............Foundation Prop. Line .,f__/:�._..- O LEACHING LINE [ No. of Lines ------ 2........... Length of each line.....Y".V.._-••-�.--•---... Total Length _��'-�?.......--•.---•. cc r� 'D' Box ...)....... Type Filter Material ......�e�?..4.....Depth Filter Material .-..- . .............................. I1- t Distance to nearest: Well .-..�+.�D............. Foundation -----/AP............. Property Line ..........•---.......... SEEPAGE PIT [ ]� Depth --.. Diameter -,;p .... Number --------J............... Rock Filled Yes e No ❑ Water Table Depth ........?,/) --- Rock Size .-L.ls .-?�3 Distance to nearest: Well .........../.Iva_?--------Foundation ... .. / Prop. Line. .._.{a REPAIR/ADDITION(Prev. Sanitation Permit# _............ ......................................................... Date ..................................I SepticTank (Specify Requirements) .........................................................•............................................................... ... ............ 3 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 Laws, and Rules and Regulations of the San Joaquin Local Health District. glome 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 as to become subject to War n's Compensation laws of California." Signed .... ...................... ---•- --......--•-•..--- Owner rr' By ........................ Title ---- .....- '! (If other than owner) FOR DEPARTMENT USE ONLY ------•-------• DATE ....1. -.. {'. .-71- --•-- APPLICATION ACCEPTED BY ...... -. --. .....r-w�-. BUILDING PERMIT ISSUED .. '....... ._ �, ........- .................. ........................................................ EI ADDITIONAL COMMENTS ..-�%�-�'.'- ,---:�� F,�`i----__-•- •---.�_ ..................................................... .........-.---•......-••....... ... --•...................I...........................I..........................................------------...-------•-•..................................................................................... ---------------------- = .-.......................------.........................I...... Final Inspection by: f'�!e� :. ! ------•--------------------------Date J.....:' ._` .. . •----••--• SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 13 241-'GB Rev. 5M 7172 3 X