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FOR OFFICE USE: Vf4" /3 :1 APPLICATION •FOR SANITATION PERMIT Permit No: --- --- -- -. (Complete in Triplicate) ee r --------------- - This Permit Expires T Year From Date Issued Date Issued ppllcation is hereby mode to the San Joaquin Local Health District for a permit to construct and install the work herein described, This application i (/made in lcomplianJceK with County Ordinance No. 5449 and existing Rules and Regulations: 12 •`£ /f �' li'QIaJ��B.• .r / JO9 AD S/CdA N . Y__ 0 C /��// GENS TRACT O rt �� �1� �! --- -- Owner's Name _- -1-- -------- :�'r 11 t - - _,-.1"�� , 1171'_M,KYt hone ---------------------------- i t � Address ----------- 0 ��---- ---, r -= -------- C Cit J� o Y ----- -- - Contractor's Name -- - _ .. _. .___ _ ...- - --------------------------------- - License # G tom_ Installation will serve: Residencepartment House,❑ Commercial ❑Trailer Court ❑ *Motel ❑Otherr---_---_ - , Number of living units:----- --- Number of bedrooms _-__Garbage Grindery'.�-_--. Lot Size ..a- - f Water Supply: Public System and name -------------------------- - --------------------------------- --------- Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ , Peat,,❑ Sandy Loam ❑ Clay Loam —rte Hardpan E] r 'Adobe,"[�:� Fill Material ----------- If yes, type ---------------------------- i .4 ; 4 (Plot plan, showing size of lot, location of system in relation tor .wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: [No septic tank or seepage pit permitted if public sewer is available within �q i a2DOpth t,) / PACKAGE TREATMENT j ] SEPTIC TANK `Size " -- 'i _ /1/ i Capacity .- 1. __Q_- TypeMatera) C Compartments Distance to nearest: Well ------ _____________________Foundation ----- -- _---_ Prop. Line __- --.-.--- I LEACHING LINE [ No. of Lines --. __-_____-- Length of each line-2J - -sr_ Total Length /�_._-_•--_._-_- s", / 'D' Box - ,�"- Type Filter Material /,�,_k_,&pth Filter Material A / Distance to nearest: Well __--?A_____________ Foundation�_Z_P---_------- --- Property Line. _- -.._----_..._-- i SEEPAGE PIT [ Depth - 1 - Diameter _ -_____ Number -..- ----"------------- Rock Filled Yes 'D?---ffo .0 f Water Table Depth -------'--- -------------------- ---------- Distance ------------- Rock Size ----,lc.---�_-_------- ��- --- Prop. Line _.3,-_.� Distance to nearest: Well / _______________ Foundation -.__.___ REPAIR/ADDITION[Prev. Sanitation Permit# -------------- '.__--__-__-_--.---____-Date ___-_______--_--_.___.--_---_-) Septic Tank (Specify Requirements) -----------------------.- - - a s Disposal Field (Specify Requirements) ---------------------------------------------------------- 4 -------------------------""_--_________-_-__--____--------.-- 1---_-_--------_".----___""-_____-___---"---""-----_------------------__---------------------------"--"---------------------- -------- -------------------_--.--------------------------------------------------------------------------------------------------- (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.accordance with San Joaquin County Ordinances, State Laws; and Rules and Regulations of the. San Joaquin Local Health District. Home owner or licen- sed agedts signature certifies the following: - 4 "1 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 I B `a '" 14'tle ----------�._w"- , Y %--- ------------------ [ her than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ----- --------------------------------------------------------- DATE r = - BUILDING PERMIT ISSUED ----------------------------------------- ----DATE ADDITIONAL COMMENTS ---.-.---- --_ ----------------------------------------------------------- ------------------------------------------------------------------------------ --�- = -� A �I�� !�-7--------- ----T ==_"_ ---------- --=--- ------------------------------------------------------------ . -------------------------------------------- Inspection b -Date _. /� _ _--_____- P Y b l SAN JOAQUIN LOCAL HEALTH DISTRICT ' E. H. 9 1-'68 Rev. 5M