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FOR oI`F1IC USE: APPLICATION FOR SANITATION PERMIT _.._...._........................•----- (Complete in Triplicate) Permit No. ..... ................. . .......................... Date issued .. "��:7� ............:..:.......... This Pere»it Expires t 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 and existing Rules and Regulations: JOB ADDRESS/LOCATION � .� �� ` � ... .:.....:: .. *'. CENSUS TRACT ................ J. Owner's Narr a ...... 1 �! � !. } , ' .......fc .........:.. .... .Phone ......... ._..... ...----- Address ..... .,..,1 ._ 1...... lz�2r�i ' .__.,. ............. ...City . ...`. ...----•----............ ....... Contractor's Name ;e :� x: �' �9 ............... ...................License # ra?. �� .. Phone . •:a. - ' - Installation will serve: Residence P!Apartment House fl Commercial C)Traller Court 0 i Motel❑Other ................:..:.......::............... Number of :living units:_. ... Number of bedroom* . ... _Garbage Grl der .......:.... Lot Size ..../...... ... ... . Water Supply Public System and name .. �1... ...................... .1. :. ........ .....................:.......Prlvpta Chorr Iter of sail to a depth of 3 feet: Sand 0 Slit Q Clay C] Peat Q... Sandy Loam 10 Clay Loam C) I . . . Hard an[ Adobe� Flli Material ............If yes,type ......... . ............ (Plot plan, showing size of lot, location,of aysten 'in,relation to wells, buildings, ate. must be placed on reverse side.) NEW INSTAkkTION: (No septic tank or seepage pit,permitted if public sewer is available within 200 feet j PACKAGE TREATMENT [ ) SEPTIC TANK;,3 ��-• " �Si>re.................. . ................ Liquid Depth .......................... II tr.Capac�ty ................. ,Type Z.. . .......Material.............:........ .No. Compartments ...................... Distance.to nearest: Well .. .. ..Foundation ------• - - Prop. Line d _ Le t r LEACHING LINE ]. No. of L:ness,:.. ; ...._-...._ ng F of each-line............................. Total Length .:....:.................... i . D.' Box # --•-•-• Type filter Materiril .:..................Depth Filter Material ' I Distance to nearest,y;,Well .............. . Foundation _..................... Property Line .. ................. .. SEEP: PIT j Depth •._..__... �Oiairr:eter ........ -Number ............. .......... Rock Filled j Yes L7 No 0 r Water Table Depth ...-----•........... ... . ..............Rock Size ... Distance to nearest: Well :......_.:.............Foundation ................ Prop. Line ...............:..,... f REPAIR/Al)DItION(Prev. Sanitation Permit# ........... ......... Date ................................ Septic Tank,(Specify Requirements) ....... :....1 �.. �� _ 22?-V= - ... - ....... . . - . ._ Disposal Field (Specify`Requirernenis) .............•-----........................................... . r , ..... -I----------------------- , ---------------_ •---�- ...... _. ...................I..............• .. .............................._........• ................ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done In.ageordance with Son Joaquin County Ordinances, State Laws, and Rules and kegulationsrof the San.Joaquln Local Health.District. Home owner or Ikon• sed agents signature certifies the following.- "I ollowing:"I certify that ilin the performance of the work for'which this;permit is Issued, I shall not a nploy any person in such i"annor as to become ''subje ` o WP-ikm-.q Compensation laws of California" Signed 1 . ter "`. ------------•--------- --------------------- Owner B ................ !� ......................................-----------illf other than owner) i4 FOR DEPARTMENT USE ONLY . APPLICATION( ACCEPTED BY _G,1.... .. ::................. DATE .._...:-J7./.a:..7 :................ BUILDING PERMIT ISSUED ..... -------------------------------.-------------------------------------------------.- ----------------DATE ....__.......-----.... ........ ADDITIONAL COMMENTS ------------------------------------- ---------------- f--------- --------•--------- ----------------- .--------------------------------------------------------- '' .. -•--•------- ---------- -------------- ........ ----•-----.-----.._._..------..._----. .Date �T , / Fina# inspecfiian by: .._... . ._.. -- -----------:......._.._._..----.......-------------... .....--- ....... ... ..�.. .?... EH 13 21� -6t3 Rev. 51Yi N JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M c .