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FOR OFFICE USE: ............. .. ...... .. .. APPLICATION FOR SANITATION PERMIT . . ....----....----... Permit No. ......7,1;- (Complete in Triplicate} __•______ ......................................................... //C- 74 .............. This Permit Expires T Year From Date Issued 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 oppli ti n is made-in c rnpfiance with County Ordi�nance No. 549 and existing Rules and Regulations: / /(/ ices-: E. W E3 4), GJ�''4 �, +u£ . JOB ADDRESS/LOC ION � fj� N . . ..S_ ................... Ulc A I? IGc9c� y�/�q�f) �CENSUS TRACT .......................... Ao ADZ... D � 3 Owner's Name ..... j.....):X/..•-- I----•-•- ------ `�_`._.._.._... 7 .............Phone Address ... ..C . /Uj -!t°......_ City/�1� T�=CA --• ....-•------- ---- ----• ..... Contractor's Name . ---- -�Lt-lt�C14 .._----- --------------License # c77J7S..f�. Phone4a.,P:�. erf�'- ... Installation will serve: Residence MApartment House-0 Commercial ❑Trailer Court a Motel ❑ Other .... .. ....... ------------- Number of living units: .'....... Number of bedrooms .......Garbage Grinder .. .. Lot Size ... f��.. ........................... Water Supply: Public System and name - ---- --------- -----...._.. ....... --•--•-- ------:.Private ❑ Character of soil to a depth of 3 feet: Sand Silt[IClay El Peat❑ Sandy Loom Clay loam ❑ Hardpan ❑ Adobe ❑ Fill Material ............ If yes, type ....._............ .4. . (Plot plan, showing size of-lot; location of system in relation to wells, buildings, etc. must be placed an reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) .r PACKAGE TREATMENT [ ] SEPTIC TANK Z ] Size---..U' 7K,. 'Y_.4--?........................ Liquid Depth __-41!_ ............1 fel It Capacity Type _W.<!`1-�F_Moterial........ . .. ..... No. Compartments I i p ,.. or Distance to nearest:,Well ��`G._ .._ .._.... Foundation .x.13.- Pro Line ._J................. .C [ ] Noof Line* Length of each line e o�6_0/.. o�^��ToaLength ------------ tI Lnth .'.�� ©•--- b 'LEACHING LINE .-_� g , 'D• Box_._./.; Type Filter Material �XgDepth Filter Material .... ......................... Property Distance to nearest: Well . •.,G �_....__..._ _ _ Foundation -.----..--•; lb_.. .. ....... _Une .157.._... SEEP#GJFPWI ] Depth Diameter ............T.. Number _ . Rock Filled Yes ❑ No J Water Table Depth ....--•--.......................................Rock Size ....-- .......... -•----•---- 1 .... { Distance to nearest: Well -._ ......................._ -••-----Foundation ' -.__--- Prop. Line ........ ; REPAIR/ADDITION Prev. Sanitation Permit# ........ ........... Date.......... Septic Tank (Specify Requirements) ............. ------------- ---------------------- ��, ;: J._... ........................_....... Disposal Field (Specify Requirements) .___. ---------- --' ................ .................. .. .... .. A .... .._..--- ...... .... • ------ -------- -------) (Draw existing and required addition on reverse side I hereby certify that I have prep ared this application and that the work will be done in accordance with San J6aquiai County Ordinances, State Laws, and Rules and Regulations of-the-San'Joaquin Local Health District. Homeowner oar licen-, sed agents signature certifies the following: `�f'J F "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 subjeto Workman's Compensation laws of California." Signed . .. s .y.�.... ..- _ Owner I 1 By . ........ ............... • ------.....-- - Title (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . _ _ 3-4 -'�3 . ..... �.. --- � -� ..---- � . ..... DATE .. . - BUILDING PERMIT ISSUED ...... DATE- w ....................... ADDITIONAL COMMENTS .. . - _lo • �- .. ....................... / --- .................... ---- -------------------- ....... ----- .. . --------_._.......-..--------- ................. Final fns ection b ._...Date _. z�, ,.�.................... ... P y: ---- -- -•-- ...--••---------- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT L3 24 7/72 3 �K 13E.-H. - 1-'b8 Rev. 5M