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FOR OFFICE Usl APPLICATION FOR SANITATION PERMIT ...........................................-............ Permit No. (Complete in Triplicate) .................... ' This Permit Expires 1 Year From bate issued Date Issued ...�.::.s.,.�b t -- .. �. Application is hereby evade to the San Joaquin Local Health4'Distrkt for a permit to construct and install the work herein desuihed. This�pplicati is made In pliance with County,Ordinance No."544 and existing. Rules and Regul�ationso //�� f , l � '� .. .CENSUS 'TP .i09 AD�RESS/tOCAT10 .- .... E Owner's Name ...:............. . . ... .... ._..............,......... ..._ ....•.Phone�7� .................. Address .. .................. a 7 d ` -4?........................City . ...................................... Contractor's Name ........... ... .:.�4P�...4.. '® .............. ", `f .... Phone Installation will serves Residence�5 Apartment House C) Commercial OTraller Court .0 6 Motel []Other -L.... ;. . Number of living units=.....C..... Number of bedrooms -- .......... Grinder '_.......... Lot Size .• 5 - -_....__.•-,�(� Water Supply: Public System and name ................................... ` ............... ._......------•....-----..Private Character of soil to a depth of 3 feet: Sand E3 Silt❑ Clay t3 Peat 0 Sandy Loam ❑ day loam Q,, Hardpan❑ Adobe . Fill Materlol ._.._.......If yes,type ,, .33 $Plot plan, showing size of lot, location of:systern.,InF relation to wells, buildings, etc, must be placed on;reverse side.I r. NEW INSTALI.ATIONt (No septic tank or seepage pit permitted if ublic sewer.is available within 200 feet,) , PACKAGE TREATMENT ( ] SEPTIC TANK 'S e.... _....lX..�Z�....................... liquid Depth ...........................- o � � Capacity �— h$"DO Type . ... ..... . Material--•-- .. No. Compartments ...................... %' `•yL Distance to nearest: WeTI . .....� .......Foundation �_-... Prop. Line 5 ...::... ........ ..................... of LEACHING LINE No.hof Lines .......:�—:__...._../length of each line........ ......... Total length ....178............ .0. Box .....�Type'Filter Material _9 .....Depth-Filter Material ..:. ............................... � -� �'' �•rte . , `'Distance to nearest: Well ........................ Foundation ....�a................ Property-line . - SEEPAGE PIT Depth _- ;:s? ....... Diameter .FA....... Number � - -Rock Filled Ye No Water Table Depth ----•---- ----------- •___.....Rock Size ....... .............0Z..... � + f Distance to nearest: Well .... .r `. ... . ..,......Foundation♦ ... Prop. line ..................... REPAIR/ADDITION!Prov. Sanitation Permit' ............................................. Date ..................... ............ , Septic Tank JSpeclfy Requirements) ........ . .............................. :.... ......................----------•----------•----....._._._.�...... ... �4 r Disposal Field {Specify Requirements) ..........................................-.......-----. ....I............... ............. ..................... .. ....................................•------....-•-------------.....------.-.....---•.._.. �` ........... ........._.._.....-- -•--..._........ .. ...-- •...................... .._.................. 1Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that ",work will,'lie done In accordant* with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or Iicen- sed agents signature certifies the followings "I certify that in the performance of the work for which this permit is issued, I ihall not employ any person In such manner as to become subject to Workman'i'CampensaHon taws of California." Signed ........ .`...------...... ......... .... ...... ... Owner 8y .........�`" ..__. - -- . Title ..................................... ................, .......... • }i of r than owner) i FOR DEPARTMENY USE ONLY APPLICATION ACCEPTED BY ..... . �. ell......... .. ..,.............,.-.:._......... DATE ..... ..r. BUILDING PERMIT ISSUED _ - '........ ................ ....DATE -..-_..---- ---.... ADDITIONAL COMMENT'S ..............:.::.... / _ ...--...--..............--.-........ ...............--.-....... ---------------- -------------------------------------- -,�C]J. t µn/ 4t...�....-..--.. ........... -.........................-.-.... ....•_ - - ,, ,� 7- ........................................................... :. ............................. ...... ... .. � --- Final Inspection by: ................... ?_ 6. �.P._...-......... ©ate Mi 13 13 2!i 1"68 Rev- 5 SAN JOA UIN LOCAL HEALTH DISTRICT 8/71 3M _t 7