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i FOR OFFICES use: APPLICATION FOR SANITATION PERMIT ...... ..........................I................ Permit No. . ....3// [Compute In Triplicate) Date issued' �-x,.75 I ........,j. ........................... This Permit Expires I 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. S49 and existing Rules and Reguliations, JOB ADDRESS/LOCATION .. j.:7 ...... ..... ... �... -t?p.................... CENSUS TRACT ........:. ..............: i Owner's Name 4 ...A............ .. ............................ ........... ........... ... ....._....... ............Phone ............................ ... Z z .. :.. - .k.............City . .' Address ...... . ... Az� Contractor's Name ........ .. ........... . -•- :.. r::.: `.___ _�__. :_._.._....License _: ..�c�_ 8 Phane ... . Installation will serve: 7 Residence ff4artment House 0 Commercial[]Trailer Court E] EMotel[]Other_.. -.....................•••-•-•-- Number of living units:-------_-... Number of bedrooms .__?t::LGarbage Grinder ............ Lot size .r... .............. Water Supply: Public System and name Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ "Clay."0 Peat❑ Sandy Loam'o/Clay Loam ❑ f Hardpan® Adobe❑ Fill Material ............If yes,type............... ............ (Plot plan, showing size of lot,.!Jocatiori of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: -. (No septic tank or"seepage pit permitted if public sewer is available within 200 feet,) ; PACKAGE TREATMENT [ ] SEPTIC TANK f ) - Size................................................ Liquid Depth .......................... f Capacity .................... Type •--- Material---....-----.......... No. Compartments ....................... Distance to nearest: Well` ___Foundation Prop. Line LEACHING LINE [ No. of Lines ................... Length of each line............................ Total Length ........................... 'D' Box --------- Type Filter Material ..... ............Depth Filter Material .................................... .. Distance to neareste Well ..:. _- ..Foundation ----_ Property line SEEPAGE PIT [ j Depth ••_•-•--,.. ...... Diameter ., =::. Number .::.............. . Rock Filled Yes.0 , No f Water Table Depth __ .....................Rock Size p Distance to nearest: Well ...........Foundation ........:............. Prop. line �. REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ............_.___.................1 Septic Tank (Speclfy Requirementsl ............... ............... -- ............. ...................._-............... Disposal Field (Specify Requirements' .-. , .-_ ., .... ........ ----•..----•• •- .......... ... . ��., . • -L� -cam - .. � . . . _.� -� (Draw existing and required addition on reverse side) I herebycern that I have prepared this application and that the work will be done In accordance with San Joaquin certify A p County Ordinances, State Laws,'and Rules and Regulations of the San Joaquin Local Health pistrict. Home owner or ilcen- ted agents signature certifies the following: "I certify that In the performanc$of the work for which this permit is issued, I shall not employ any.person In such manner las to become subject to Workman's Compensation laws of California." Signed ................::............. . _ ......... Owner , imss. ..........'................•. By ....................................... ............ .. ... .....- .... .r ...... Title�`-�' {if other than owner! FOR DEPARTMENT "USE ONLY - r APPLICATION ACCEPTED:.BY.-.-.-.e/............... ................ DATE....::5- ,:5. 7 J.;.............:_ BUILDING PERMIT ISSUED ................ .DATE ADDITIONALCOMMENTS ............................. .................................................................................................................................. .............................................. '. ............. .......-.. . .... .................. ....---. .. ......................-._..................................................--.... ... ................................... .. ... . ..• __ . . ...-. ..... .._- . .................... FinalInspection b �.... . .....................................................................................Date ....... EH 13 2h 1-68 R6v. 50 SAN JOAQUIN LOCAL HEALTH DISTRIQ 8/7h 314