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a 1 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ........ .... ..................................... Permit No. ..7�.��6.. (Complete in Triplicate) ...................I.._........ ..1�:"�'71`_`... .................................I..............__..... This Permit Expires 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: JOB ADDRESS/LOCATION ........ -`Gi ... .. ..f .. ._ ...... SUS TRACT .•............:........... r Owner's Name ............. 4, . ...... ..... ..............,......._.. ne ......-----.............. ........ Address ------- ---- City Contractor's Name ....C_ . . License # Phonerr + Installation will serve: Residence ❑Apartment Housed 5pmmerciol Trailer Court 0 Motel XOther _ _. Number of living units.. lumber of b rooms _._.. .....G//►► age Grinder '_ -- --- 1`ot Size .. ..... .......... Water Supply: Public System and name .. ....:C ..._..........................................Private,' Character of soil too depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material .....__ ---- If yes,type ............................ (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc, must be placed on reverse side.$ NEW INSTALLATION: JNo septic tank or seepage pit per4ttedji public sewer is available within 200 feet,$ �+ r, PACKAGE TREATMENT ( ] SEPTIC TANK I ] .r -Size.----.- r rf ..l--�.._. Liquid Depth ...J,5 ................. Capacity --- ................ Type ....._.............. Material...................... No. Compartments ..........----........ . Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE ( No. of Lines ./------------------ Length of each line--- 0_r.___._ .. Total Length 13-a.............._._. D' Box --/------•- Type Filter Material ._,/...Depth Filter Material ... '� ..................... f -?7[6� nce to nearest: Well/4V.............. Foundation -��_......_...._.. Property Line ................. r SEEPAGE PIT Depth a4s—.--------- Diameter ..._..... Number ---------e! . --------- Rock Filled Yesi No ❑ Water Table Depth ._ ............. Rock Size .. .f............. w--••••...---- Distance to nearest: Well ... �iO�.. ......................Foundation ....41 a---__-_ Prop. Line-$.................. REPAIR/ADDITION(Prev. Sanitation Permit# ....--...- ..... ................. Date .................................. Septic Tank {Specify Requirements] .__.. --•--••-• - ---------. t.. � �" -`_......F1_•• �, Disposal Field (Specify Req ments) -------- ----- - ----- - ------- -- -- •----- -------------. --" "'--• r' ......_..... �........ �.__. mac............. `( w existing and required ion on reverse 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 ------ -- __- - - - -•--------•------- Owner BY •----.. E -..._...._.. title ...... .....__...-•--------- (if other than owner FOJ DEPARTMENT USE ONLY J APPLICATION ACCEPTED BY ... ..................................................... DATE ............................. ---•-•------ BUILDINGPERMIT ISSUED ........ ........... .......... -•---......_....._..........................................DATE ........................................... ADDITIONAL COMMENTS ... oo�.....ri.... i%s-...:.. ......................................................... ............................................. ........................................-............................................ ._.. ---- • -----•-----•----•........ --- . ----- -- - -- Final Inspection by: .. ._........... .. c...... ....._. ..................................................... .................Date . ..J'il .7. ... .............. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.3-3 241-'b8 Rev. 5M 7/72 3 .K