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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r =- �� Permit No: ------------a-----------_.---------- ----- (Complete in Triplicate) �? U/14 p7 ; is- o ------------------ Date Issued ---q ---- This Permit Expires 1 Year From 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 compliance with County Ordinance No. 549 anJd existing Rules and Regulations: • L g 2- ` _CENSUS TRACT _--_r../---------------- = JOB ADDRESS/LOCATION . -I d --�Lr--Y► 'O ,,,, ---- --Phone ----------------------------------- Owner's Name ---,9---✓i'l--------- GL° -TGf3- - - 'E' - - Address __-674�P -`?- ---AF -/A4y---- Z �f �fQ_11Cn'7._:. City ------------------------------------ License # ---------.-------------- Phone --------------- -------- Contractor's Name ------=- -- --- --------- -------------------------------------------------------- -. Installation will serve: Residence 0 Apartment House^❑ Commercial :❑Trailer ',E]�� Motel F-1Other --AA-4-fl--f"-�'_ _/,� l yZ ber of bedrooms -)--------- Grinder7_1V& "- Lot Size Number of living units:____tr------ Nu Privatey Water Supply: Public System and name ___--------------------------------------- Character of soil to a depth of 3 feet: Sand'[:] Silt[] Clay ❑ Peat❑ Sandy Loam 0 Clay Loam .Fr Hardpan ❑ Adobe [] Fill Material ------------ 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 public sewer is available within 200 feet,) ` C PACKAGE TREATMENT [ j SEPTIC TANK, Size_ ✓L Liquid Depth W Ql� ��_._ Capacity .-.-___f yi pe IV-If -C �Material_�Cn'�------- o. Compartments � Distance .o nea est: W a ___--Foundation ---,�-Q- ------ Prop. Line _�� _-------- _ ____________ Length of each line._ ---- .------ Total Length 10 �----------- Q_ g -- LEACHING LINE [ j No. of Lines __2_- -- � - a _ e th Filter Material _ ----------------------- r 'p' Box "�__ -- Type Filter Materiak --- 1p �__C�_j Distance to nearest: Well __2QL3---- ------ Foundation -- -------- Property Line [ ] Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No .i❑ SEEPAGE PIT Depth WaterTable Depth -`-----------------------------------------------Rock Size -------------------------------- Distance to nearest: Well --------------------------------- lFoundation --------- ---- Prop. Line ------------------------ • _______ j {._ .-. _ ---- Date -) REPAIRfADD1TlON(Prev. Sanitation Permit# -------- -^-Y----- - , Septic Tank (Specify Requirements) ----------------- - - --- ----- ! Disposal Field (Specify Requirements) ------------- --------- ------------------------------------------------------------------------------------------------ --- --------------------- ---------- ------- -----------------------------= 6 (Draw existing and required addition on reverse side) I hereby certify that I have prepared this applicationand that the work will be done in accordance with San Joaquin j 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 performancerof the work for which this permit is issued, I shall not employ any person in such manner I as to become subject to Workman's ompensatior6laws of California." Signed - ---- ------------- -------------------- Owner - -- - -------- --=---------------- ------------------------ Title ------------------------------------ --------- - ---------------------- (If other than owner) I FOR DEPARTMENT USE ONLY DATE APPLICATION ACCEPTED BY _.- --- -- ---------------------------- ----" DATE BUILDING PERMIT ISSUED ---------------- - ---- ------- ADDITIONALCOMMENTS ---- --- -------------------------------------------------------------------------------- ----------- ------------------------------------------------------ --------- ----- ------------ ��. ------- ------- , ----- - - _ f -------------------- ----------------------------- .Date ------- ~----�- ---- - -- --•--- Final Inspection by: ? --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.