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FOR OFFICE USE. APPLICAT6W FOR SANITATION PERMIT .............. ............................ Permit No. �� j•--• (Complete in Triplicate) ............. ..............................................:...... This Permit Expires I Year From Date Issued Date Issued-.;G-_2_6-.73 1 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. 49 and existing Rules and Regulations: J06 ADDRESS/LOCATION .-.... U i..... :.� 11r�� d. . ......... .... .....CE A ........... !�(/ ....CENSUS TACT Owner's Nome . . ........I..-.d F%.r c �� ..._................................ . ...........•---... .......-_....Phone ._.... .................... Address .................. . . . 4' :. -...._............_.._,_.... City,, ..................... Contractor's Name .... ... ............:. ............ .................License ,# �I�- ..... Phone .jj�/ � �1�l ? h�!................ I Installation will serve: Residence partment House C❑ Commercial❑Trailer Court 0 Motel ❑Other .............................. Number of living units:-----t.... Number of bedrooms ,__....Garbage Grinder .- ........ Lot Size Water Supply: Public System and name ........................................................... Private __ . ... .. ..................:.... Character of soil to a depth of 3 feet: Sand❑ Slit❑ Clay Peat Sandy Loam ❑ Clay Loam ❑ Hardpan❑ Adobefil Material -....,14e4f yes,type ....-_._....... ........ (Plot pian, showing size of lot, location of. system in relation to wells, buildings, etc. must be placed on reverse side.) I NEW INSTALLATIONS (No septic_tank,or seepage pit permitted #f-public sewer is available within 200 feet,) PACKAGE TREATMENT 4 ( J SEPTIC TANK,�j Size..... Liquid Depth ...L.�:�.......... Capacity,-_--.- Type ,�i Liar Material.��x rr Na. Compartments i Distance to nearest Well `� / t Foundation �. ... Prop. Line No. of lines (9' e�-- Length.of ch line.. LEACHING LINE .. .. Total lengtha ........... 'D' Box Type Filter Material _ -_, _4�k...:.Dept Filter Material e 4 �.a i1 M. Distance t nearest: Well.... ,a :...'...---- Founddtion ..................... Property line ' k - SEEPAGE PIT [ Depths- �.r.. " `Dia r' ` :.:Number ...... .... ed Yes 0�`i�o❑ •--- �,......_.... Rock-Fill i Water Table Depth ...... .. ..................................Rock Size .. �2—. �..... ... Distance to nearest..-Well l rWell ..............................Foundation .. .�. ..-.-. Prop, Line -........... REPAIR/ADDITION(Prev. Sanitation Permit 9 ............................................ Date ..................................) Septic Tank (Specify Requirements) _ - s Disposal Field (Specify Requirements) ...K................................................................................ R...--•. ...... ....................................... ............................................_......................... ..............._:.....------•................-...............- (Drow'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 County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Iicen- sed agents'lignature 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 pf California." Signed ...... .............. 1F Owner By ..................... ......... .. •--•-- '........... ............�} title n, _ .. . (if other. ..an nor) .,' F R DEPARTME NT USE ONLY APPLICATION ACCEPTED BY ..:.. ... BUILDING PERMIT ISSUED DATE ... . .�. Q.� 9 a ..DATE ADDITIONAL COMMENTS ............................I.."..:....._...._..........._....._..- ............................_._...........-......:� .......... .. ....._._.....-....:......._.....-............._"__..........-..........-_. ........_--_..-..-............. Final inspection by: --....Date �, .........................., ... . .rr :. ti �..,>SA,'•JOAQUIN , L HEALTH DISTRICT 24 13 z E. H. _ i-'b$ Rev. 5M � 7/77 1.M