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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ...7s~".._..:�.G :. . , This Permit Expires 1 Year Prom Date Issued Date Issued .- :.2-�..... Application is hereby made to the-Son 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: JOB' ADDRES ION . . .__. '_1D._._._..'NF- .1 ._. :,J...............................CENSUS TRA Owner's Name. - _1... .. f t '-..f' / ll ! . ...................... Phone _ ,T_. ,'••�••, / . Address .7�.`T C1..��` .. . ----------- city G/ '1�.r� .............................. ..,�------------------- - .. � ... ......... ' Contractor's Name license # 1 . ...._ ... Phone . ...... --•-------. ..................... --...---...................... Installation will serve:' Residence.p'Apartment House Commercial❑Trailer Court 0 Motel Q Other --------------- ............................ Number of living units:_. /----__ Number of bedrooms _ _ ____....Garbage Grinder .._- . ,Lot Size ._..�.� � ....-- Water Supply: Public System and name ....................... ..................`....-.......................Private Q� �.. Character of-soil to a depth of 3.feet: _Sand -WSilt[J - Clay- [J. -:meat Q,Sandy_Loam-Qis_CIay-Loam Hardpan [] Adobe Q Fill Mgterlol ............ If yes,type............... ............ {Plot plan, showing size of 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 pub) sewer is available within 204 feet,} r Y PACKAGE TREATMENT ( 3 SEPTIC TANK Size._ ....- - .............. Liquid Depth .......................... Capacity .-:� �- Type &7�Material................'..... No. Compartments ... —......---•.� ';. . Distance. to nearest: Well f©D .....................Foundation ._ o.._.........`. Prop. Line -- 0.j-........ LEACHING ZINE ,( "] No. of Lines _ __- Length of each line._ .. f `_ Totdlf length 1 ----- rl .. . . . ` D' Box .-_.. Type Filter Materiall.l...�.,Depth Filter Material,...... ................. Distance to nearest: Well _...:�d .....,,. Foundation ---Zo............. Property Line ........._....... SEEPAGE PIT [, Depth . --- -= ramete o __---. Number ------- ............�... Rock Fill d Yes. No �] _.._� J f�................. .............Rack ........... 2................. sa Distance to nearest: Well .....� '...............__-Foundation .__-- -- .. ...... Prop. Line .._ ....:�........� REPAIR/ADDITION(Priv. Sanitation Permit# -•-:-----------------_- _ ---:----.Date ................................... ) i Septic Tank (Specify Requirements) ---:..I------- --------------------------------•-----.......---------- ---- ---- ... Disposal Field (Specify Requirements) _________-. _ 4 " 4 ---•- -• -------- .. - •------- ------ --- -------------- -----------................................................. ........................... {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 with San Joaquin '4 County Ordinances, State Laws, aced Rules and Regulations of the San Joaquin Local Health,,District. Home owner or licen- sed agents signature certifies the following: 9 i l "I certify that in the performance of the work for which thisermit is issued, I shall not employ I p p y any person in sorb manner as t sub( to Workman's Compensation laws of California.#, Signed 414 - --• -------------- ---------•----- Owner By -------- ----------------------------------.---------..._ -- • ---- Title ----- --- ------- ........ � (If other than owner) _ R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _. :{..-._ ._.. G '-- ---------�Gfil.�il_��... DATE rj.— BUILDING PERMIT ISSUE© _.. ..�._...... --•••----..... ©ATE ._._ —----------•-------------- ADDITIONAL COMMENTS ..............l.____•._._..----.-.._.._ --- -----------------------••--------------------- ------------------------------•--•------------------------------- •- ---------------------- -------------------------------------'----41;� -- ---------------- ..-..._....-------------.--------------------- .....--------------"-----•-• --- ------ ------------------------------ ---- .....--- -+ . Ina Inspection by: -•- _ ____-• • Bate - - El•l 13 2h 1-68 Rev. 5m i� SAN JOAQUIN LOCAL HEALTH DISTRICT $/7)j 3M