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f � FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...... ........... Permit No. {Complete in Triplicate) -....... .............................................. `{ ............................ This Permit Expires Cres 1 Year From Date Issued Date issued ..�:�� Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made,in compliance with County Ordinance No. 549 and existing Rules and Regulations: I � ... .L. ... r �� ............................ ......CENSUS TRACT . ...........JOB ADDRESS/LOCATON � . ............. ,j Owner's Name ..... ,... Phone .. !- .................... �� ! AddressR�-- - -1.......... t. City .........I...... _.r.............. — -2 -e-�.C-License # r f7� Phone .E� ...Contractor's Name 4.-= ... -�^�`�-• ._ .. --- -- :..... t Installation will serve: Residence,VApartment House-0 Commercial ❑Trailer Court ❑ Motel ❑Other ---------------- --------------------------- Number of living units:.-/..... Number of bedrooms -."...Garb a Grinder '�- Lot Size -.�7. •_.. ------•�---•-•- Water Supply: Public System and name _- g .-..-•---------- ...................... ---...-----.......Private ❑ Character of soil to a depth of 3 feet Sand❑ . Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe y Fill Material ....-.._.... If es, type -------------- ----- I (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,yank or seepagerpitp�r if public sewer is avail oble.w;thin 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK t ] z_rtS / Siae................................................ Liquid Depth .......................... Capacity ..... Type -------------------- Material---------•-•.......... No. Compartments ......................S ` � r - o nearest: Well .............................Foundation ------- .............. Prop. Line ...................... /-............. Length of each ine----- ..-_�. -..... Total Length ,... ......--- ... Distance t LEACHING LINE � No. of Lines ----.- -. ,al � -•- 'D Box ------- Type Filter Mater .....Depth Filter Material .- �. ........................ -..... Distance to#nearest: Well . : '� --•---••- Foundation .` .............. Property Line .. ••-•-•-----• SEEPAGE PIT [ ) Depth ---•. ............. Diameter ....-...-------- Number . ................... Rock filled Yes (3 No (] • y . ' ........Rock Size ................................. • Water Table bepth ------------------•---••---•--•--•----•• Foundation ..-------- .. Prop. Line -------------- Distance to nearest: Well ........................................ ...... ------- REPAIR/ADDITION(Prev. Sanitation Permit#1-—---------------- •-•••••--- Date ..................................1 Septic Tank (Specify Requirements) -------- •---- �/ ---•---•--•--•---•.............:...............•••-_.... ¢ -_-5 w-, Disposal Field (Specify Re vireme�ts� _ { f ---------------------•--.._..--- f .. .. ��----------•-• .......... . ---------- ------- ,. ....... .. -- _.--- ._ 2 'r-o' �cr�y.ur.-lis:_ '� (Draw existing and required acl it io a reverse i e) 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 Workman's Compensation laws of California." Signed- Y+A ... .....--•-•---•--•-----•- Owner r C .:. By -•----....-... -.:.. L _..--------_--- . 3itle (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _.... ...............•----------•---•-•••--_. DATE ...-..... . -1 ...7 ......... BUILDING PERMIT ISSUED ..... .................... -----------• --------------- ----.....DATE ....-........... ADDITIONALCOMMENTS .............:..--...........----• •---•-•------•--••......•------ ._ .........-----•---•...........-•--•••-•.............------ ..............._........ ....................... -•------------_--------- f --------------------------..----•-----------------•-. , _.. :.. € Final Final --..-..cti ---...-•-----------••-----••...Date ....� :1 Inspection by: ......---•----•--.......-•.............. - .fi• - SAN JOAQUIN LOCAL HEALTH DISTRICT X111 6 ' c u 13 24 1_-,&a cs., qm 7/72 3-M