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FOR OFFICE uSE: APPLICATION FOR SANITATION PERMIT ,,// .................................. Permit No. .... ..r�5� (Complete in Triplicate) ................. This Permit Expires it 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.Coi.HVy Ordinance No. 549 and existing Rules and Regulations: _ ff 108 ADDRESS/ A N ...... l..:._.. ..... �°.r `.................•-- . ..CENSUS TRACE .............. Owner's Name ... __. . �-...4;_:-. . _�/.�`�..... -------,--•---........ .Phone Address ._.....---. - - .r Cit .. ...... Contractor's Nome .. . __ f ]�`?` -- -aCa...License # .1.t _. YPhone .................. Installation will serve: Residence Apartment House] Commercial oTrailer Court I] ! 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 0 Silt E] Cloy 0 Peat❑ Sandy Loam Clay Loam 0 Hardpan ❑ Adobe j] 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 see ge pit permitted if public sewer is available within 204 feet,) PACKAGE TREATMENT [ SEPTIC TANK[� "ze l'�-- ---� ./--•---.... Liquid I?epth .�� ...- lQ f Capacity -�pjq_P.-_-- k, Type -. :-.---..._ .. Material--�'f ------- ----- No. Compartments ..rZ.-............. Distance to near st: Well __.____,—rQ_.�............Faundation ....i' .... Prop. Line .....�. .......... LEACHING LINE VNo. of Lines .... ��............. Length of each line.......�'.�.�...... Total Length _.�-_`I`� _........., 11 __ 'D' Box .....1----- Type Filter Material........:A,.k...Depth°F=_ilter Material ......./-.e7...q.............. ......._•_•.._...... ........ r.----- I Distance to nearest: Well ........�'�..� Foundation ...._.. ..... Property Line ..... .............. SEEPAGE PIT [ ) Depth ................... Diameter ................. Number.............................. Rock Filled Yes C3 No ❑ Water Table Depth ....Rock Size Distance to nearest: Well ........................................Foundation .............. Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ...................................... Date .................................. ' Septic Tank (Specify Requirements) -------------------..................................................................-----------------------............__................. Disposal Field {Specify Requirements) ----•---- ........................................ ---------------------------------- r ---------------------------------------------------------- ................................................-------------------------- --.......-•---..... ....................................... (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. Hayne owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Work Compensation caws of California." Signed .............................di, --•----- ......Owner X ..._ �� ------ -Title --- ' _ ._......: By .._..... Eex-e . . .._._�Q.._ .�....................... (If other than owner) L FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY... _._.. .... ...... ........ ...............-..............-.................... DATE ............ BUILDING PERMIT ISSUED ..--•--•----•----•.............................•-_._ ....-------------_.........DATE --•------••-•--•---- ADDITIONALCOMMENTS ......................................................................................................................................................,_------ ................................... ........ ..I..........-----.........---- .......................•..............................._.........................I....................... ------------------------------•--------- --------------_-_ - - Final Inspection by: _.. ... .............................................................. ------.Date n!r.`.. ... .. ------. ..---.--- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 13 24 7/72 3 M E. H. t-'68 Rev. 5M