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i FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' Permit No. ------------------------------------------ (Complete in Triplicate) ' --- -------- --------- -------- -- Date issued:;----F �- - --`�I-7� ' `` ). This Permit Expires 1 Year From Date issued work rein Application is hereby made to the San Joaquin LocalHealthDistrict inar a permit and existing Rulestalnd hRegulat ons. described. This application is made m compliance Y :1 f ----.CENSUS TRACT ------� •-------- c ,� ---- Jbl3 ADDRESS/LOCATION .__. .� �=-.--- �. tl _ _ _ _. . ..--�- - 4 Owner's--Name ---=-_—�==-=�-_---� - n cit 5 0 ----------- '------------ Addiess 11`� -- � N � ------F�r'�------------------------------- Y / -i �. Contractor's Name- 'f-�-----•-- ------License # .�-��- --- Phone Installation will serve: Residence ElApartment House❑ Commercialrailer Court . aMotel ❑Other ------------------------------------------- i i g y Number of living units:-__ __._ rba a Grinder -----___ - Number of bedrooms _. -____ __Ga ___ Lot Size ==:--- ------------------ — —---- --------------------PrivF]ate Water Supply: Public System and name --Ie ,� (/ Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑ Peat❑ Sand y Loam ❑,r;.`Clay Loam ❑ y { Hardpan ❑ Adobe>< Fill Material ----- ------ If yes,type - -----------------------J� E r (Pl'ot plan, showing size of lot_, location of system in relation to wells, buildings,Zetc. must be placed on reverse side.)' t q �'f 3 seepage pit permitted if public sewer is available within 200 feet,) NEW INSTALLATION: (No septic'onk or SEPTIC TANK' i Size----A X1a-------- --------- - Liquid Depth , -_ -=.'•.=".-: , PACKAGE TREATMENT [ ] [ ] FI - �____ No. Com artments ------------- Capacity - Capacity':.5�7 - Type e. - Material P F 41 M ', ---Foundation.----- ---------------- Prop. Line -�. I[A 3' Distance �to nearest: Wel! ______________ i ------------------- I LEACHING LINE [ ]� No. of Lines ------- 1------------ !Length of each line____ QC .]_.------- Total Length �_- � ----------•- 'D' Box ._ice_-- Type Filter Material _tejgr_.Depth Filter Material �r = r � - Property Line. -=.•----------------�---- o nearest: Well ------------------------ Foundation ----------------- P tY ~__ Number ------- --'-`- _ _ Rock Filled Yes No i❑ s a � � F ---------------- Distance i. i ! SEEPAGE PIT ( I Depth T - --------- t �' l ' bl'e, Depth t - --Rock 5ize=_�_ 2___� f _ --- -1J • 1 _-_--:_-Foundation -------------- ---- Prop. Line;;_ � Distance.to nearest: Well -------____________•-- ---.---.-- _ t I 1 ! L REPAIR/ADDITION{Prev. Sanitation Permit ------- - ------- ---- Date ------= ------•------------------ {Pr � G Septic Tank {Specify Requiremen41 ts) ---------------- --------------------- - f - -- II (..- ---------------------------------------------- ------------------------ ---------- Disposal ----- -------- 1 Disposal Field (Specify Requirements) -------------------------}---- i^= ? 1 � I _______________�r- __T-_ ___;__---_______--__. _-..__N_'___-___-____________-__�T_______ ______-____ �. t I` _____________________________ _ _ _ _____________________________________ 1---- t- i� i i, ----------------------------------- ----- ---------------- -- ----------- - [ #� (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 wit}i�5an Joaquin County Ordinances, State Laws,'and Rules and Regulations of the San Joaquin Local Health District. Home'a ner or licen- sed agents signature certifies the,following: } ;ry i "I certify that in the perfarmance'of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to..Workman's-Compensation-laws of California." �I r ` - _ ten.09Z _ 'F ✓------------------- --------------------- Signed- w......-- __._.. p .-�.-�.�.-._.�__---�-'--------- ------------- f 1__ _ i ------------ Ti (If other than owner) FOR P, itTMENT USE ONLY APPLICATION ACCEPTED BY _..= _--- DATE -.� l - BUILDING PERMIT ISSUED ____-- -- ------DATE ------------- -------------- -------------- ADDITI fNAL COMMENTS-_ ----------------------------------------------------------------- --- -- -------------- - r - - - --------------- --------------- i - i --------- 7� -------------- ---- - --------------------------- ------------------------ _ --- ----------------------------------------- - Date i Final Inspection b � N J AQUIN-10CAL HEALTH DISTRICT I E. H. 9 1-'68 Rev "..