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FOR OFFICE3�SE: APPLICATION FOR SANITATION PERMIT '' Permit No: ------C? (Complete in Triplicate) ` -------------------------------------------------- Date Issued --! -- 76 i This Permit Expires 1 Year From Date Issued i ------------ -------------- - --------- ------------- 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. 549 and existing Rules and Regulations: t � �.CENSUS�TRACT -------------------- JOB --------- -------- ' JOB ADDRESS/LOCATION ._-i_ �_ � - f--v-- Owner's Name - ------------------ Phone H Address ------------------ -- ----- - -._.. City ----- ------------- - Contractor's Name -------------- ----------------- License # -g�'��.... Phone r Installation will serve: ResidenceXApartment Hej,ouse-r] Commercial ❑Trailer-C6urt ;❑ Ix Motel ❑ Other -------:�Jv 7 --- J/ i �0 : Number of living units:.-- _ -- Number of bedrooms --- __------G` ba a Grinder - -_._-. -_ Lot izeo - jet--Cl---- -- - -- ---------- --------- ---Private 11Watelic System-and name ------------------- rCharacter of soil to a depth of 3 feet: Sand❑ Silt❑ Clay! I-I'lPecit d Sandy Loam;❑ Clay Loam :❑ Hardpan ❑��lAdobeX Fill NMrrteriall ------------ if yes,type ---------y------------------ (Plat plan, showing size of lot, locationlfof system in relation' to wells, buildings, etc. must be placed on reverse side.) IN NEW INSTALLATION: (No septic tank or seep ge pit permitted if publ sewer i available within 1200 feet,] t SEPTIC TANK; Size----- , d. f� Liquil Depth -- -------- PACKAGE TREATMENT [ ] [ j I Capcit; - ` TYPe zRM_at�rial --- No. Compartments . Distance to nearest: Well ____ `� - Foundation _� p• �d - y 4 _-- ----7�_ _- Pro Line y 1 } ! Q -i-- Total Length ----`r-----C� ------ LEACHING LINE [ j No. f Lines ------- -------------- Length of; a Bch lined_ - - - J e� o t. �� I ! �_ Depfih filter Material ---- / --------------- I 'D' Box .-- Type filter Material �[_ - �� ,��- r�, D'rstance to nearest: Well ---------------------�-- Foundation ---�Q- "---- -- Property Line -rQ-- -------- SEEPAGE PIT [ ] Depth . s 7 toiameter - -- Number --------------- --------- - Rock filled Yes ❑ No i❑ --- ---------- ' 41)/6)1/Q Water Table De --------------------------------------------Rock Size �.All ---- pt-h, Distance to near rest: Well ____----__-----------------------------Foundation �0-- - --- Prop. Line ---`C2.._"f"_--- Dae ' - ) REPAIR/ADDITION( rev. Sanitation Permit# Septic Tank (Specify Re uir dents) -----------16 . : Disposal Field (Specify Requirements) -------------------------------------------------------------------------------------------------- s ----------------------------------- ----------- ------------ •--------------•--------- (braw existing and required addition on reverse side) 4 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, I shall not employ any person in such manner as to become subject to Wo�km6's Compensation laws of California." Signed -------- -------------- c tL'�� V`4--- Owner - ------ -- --- - ---- �.. • By ------- --- - --------- .---- Titley -- ---------- (If oth han owner) . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ---- -- --------- DATE _ 5�7U----------------•-•-_--- ---- -- - - - --- -- BUILDING PERMIT ISSUED i ------- ------ - ----- - ------------ --DATE A DI I NAL COMM.E�N-TSI1--�. f°9� �4 ` � -� - -------- - -- -------- -. - -------------------------------------------------------------- --inal-----------tion--- --- -------------------------- ----------------------------------------- -------- -------- ------- Final Inspection by: - Date -tel -- - -- - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M