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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. lCampfete in Triplicate] This Permit Expires I 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 c mplionce with County Ordinance o. 54 and existing Rules and Regulations: JOB ADDRESS/LOCATIO .'Cr1.. ._ P .cc.. .S .............................CENSUS TRACT .......................... a Owner's Name -•-•_. . ..�.. ----•....•................................... .. . ..Phone v ....2773...••... ��j �' Address . . ........... ...... Z• ?�'LiVt-.tFid-.._..-17.) .. City ....... . ._. .__..License tl� f- j W. ... 6.7.. Contractor's Nome ----------- :.. .. .. . ... .. ....�_..._..�'�-.�J........-........... .....-_ Phone .. .. �° _�6 .- Installation will serve: Residence❑Apartment House Commercial OTraller Court Motel Ei Other ...�t 5- `.SJ"... ... . - r Number of living units_____________ Number of bedrooms __---.----Garbage Grinder ............ Lot Size ............. Water Supply: Public System and name --••--• •.........................................•-•----..._........................... ---................Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam ❑ Hardpan❑ Adobe 01 Fill Material ............ if yes,type ............... ............ (Plot plan, shows g size 6f"lot,' location 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 Si e........... .r'-}� -r------- Liquid Depth .....1��.. ........ Capacity j - Type - -.- :. .........Moteriol!4C 1�.:.... No. Compartments ....Z....... .. Distance to nearest: Wel ........ Foundation --L - ----...... Prop. Line .. .. .......... LEACHING LINE No. of Lines ....... ........ i { I f :' Length of each line-...:_ {�.8............. Total Length ..61............... "" . '_--•- Type Filter Material .. ... .... ........Depth Filter Material ..../. ...`•........._........._....... r • Distance to nearest: Well ___.,c7 f9___- ..__ Foundation .----1:�... -------- Property Line ...................... SEEPAGE PA, Depth I - Diameter Xw--_- Number ---------------------------- Rock Filled Yes No j Water Table Depth ----_.............................. -----...Rock Size 3�/ � _.�+r2r`�.---•-- , Distance to nearest: Wel! _---- �r........r:f _. ._......._Foundation ._10-`..f'..... Prop. Line ...- .: ....:.... , 4� REPAIR/ADDITION[Prey. Sanitation Permit# ----7-s7-- pV--------------=------- Date ....7�11/). .�_.........} Septic Tank (Specify Requirements) '. �...�_--•----------------• ---........---•--------.................................................................... Disposal Field (Specify Requirements[ ...............• ._--------- ------- ----•------ ------------•---------- ........ ----- .....................--.................................................................. (DFaw 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. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall not employ any person In such manner as to become subject to Workman's Compensation laws of California." Signed --.-•------ -•-----------• --------i- ---- ------- - ---------•----••--•------------------•--- Owner By ..._.__.-. Title '. ` .. Of of r hon owner) - � •�'�FOR- EP RTMENT USE ONLY APPLICATION ACCEPTED BY - --•- ---------• --- DATE --------------- BUILDING PERMIT ISSUED .....-•----- ....... --- -- - ---------- --------..--------------........ ---------_--.DATE ------------------ ----- ADDITIONAL COMMENTS ........... ........ -------------- - ---I.......................................................•-----•----------------- --------•------------- ------------------------------------ ........................................ --------------------------------------------- Final Inspection by: --------------•- - - .- -- ..._......----Date ...._.-.-/-a. �3 13 24 i-E� Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M