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FOR OFFICE USE: `: APPLICATION FO.-If SANITATION PERMIT :............ 1. (Complete in Triplicate) Permit No. .. This Permit Expires 1 Year From Date Issued Date Issued .,�`�---/ff,•�S� (d-3 IV ��-f--r-� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein caw described. This application is made in complian ith C.puT O dinance i�. 549 and existing Rules and Regulations: !Y , Ste4 :tea, � _. .� :.. , ..t"r.^... ''-fi - �.;a.._i ,&7...----•.._.CENSUS TRACT JOB ADDRESS/LOCATION ._._. -' ......... ...... Owner's Name , . a :.. f �,1 t ..........................................................:. Phone Address ............................•-.............- `-----•=---•-----------------..----•.................... C1#Y •••••-••.....••--•••-••-••---•••--•••••-•••-....----........................ Contractor's Name ........... . .ir :_.. _t :-----\4.*.N� -.:-..-0_-jt..,_.....License # ... Phone Installation will serve: Residence C�AApartment Mouse C] Commercial 'j]Traller Court 0 I Motel E] Other ............................. Number of living units:......!-.__- Number of bedrooms..__.._a---,Garbage Grinder :._.___.._.. Lot Size ----!_ Water Supply: Public System rand name ...- ------Private Character of soil to a depth of 3 feet: `Sand❑ Silt[] Clay Peat 0 Sandy Loam 1] Clay Loom l] i Hardpan ❑ ""ZFill Material _..._..___.. If yes,type -- t (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 ublic sewer I� available within 200 feet,} , I ` c �` P " V PACKAGE TREATMENT [4 SEPTIC�TANI< Size. :..................•...__..__._._ liquid Depth ......... Capacity r. " Type t`' � Material.•.- --`. No. Compartments ................. Distance to nearest. Well ....................................Foundation 1.. Prop. Line +3 � Qom • LEACHING LINE No. of Lines --• --------------- Length of ach line-----rs-...........__.._ Total Length ..lj..G ... •� Material --, -- " �----Depth Filter Material .__ -•.............................•_ ... Foundation ..........:.. ....... Property Line .�-------•--•---•_-• Distance to nearest: WeUeC:.-3�...._.. .... SEEPAGE PIT Depth ._..1A.-�i........ Diameter .?..... Number ....�... Rock Filled Yes 20 No ' Water Table Depth &.!�?._. ..Rock Size Distance to nearest: Well .........f.............................Foundation_....__-•....____.... Prop. Line .�'................ REPAIR/ADDITION(Prey. Sanitation Permit .............. -------- -------------------- Date ) Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) -•••-••---•-•••--• ------------------------ •--•-----•---------- "----------_.........._..................... ---------------------------•--------•-----•--------•- ----- '. ...............................................................:_....-------........::._. .r........................................................................... --•-----•-- (Draw existing and igquired addition on reverse side) > and- than the work will benne in accordance with San Joaquin I hereby certify that I have prepared ;his a`pPlilcationCounty Ordinances, State Laws, and Rules and Regulations of the'San .foa7u qw ocal Health District. Horne owner or Licen- sed agents signature certifies the following: a~. "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 Work an's Com' pensatlon laws of California." Signed _._......_. y Owner By ..� �+ 4 --------•----- "'"...--...'.Title .. r...................................................... ( other than owner) - ,1 �. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY`-.—r-AZ- -- ----- --------=------------------•-----• DATE .. .. .... ......= BUILDING PERMIT ISSUED .......:...............:- •... .. ...................................DATE ........................................... It COMMENTS .............................................................................................................. .....................................................................:...........................-------I................ ---•---------•-...�•------.._...............................- --_......... ... r -- = ..............b _ - Inspection . ._.....--•-•--...x„4y.,.r•,�..�.._•�.:r�rr%1.� Final ,�r .�........Date ...,7. .:rte .: �.............. .. 7�`� �� u�/ .,� SAN JOAQUIN LOCAL HEALTH DISTRICT C13 i E. H.1.3 24 1-'68 Rev, SM `v! 7/72 3 M