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FOR OFFICE USE: APPLIC TION FOR SANITATION PERMIT rt. tr0 , c� r [Complete In Trfpllcate) Permit r' ..... Dote Issued hi ........................................... TPerml!Expires 2•Year From Date laved V Application is hereby made to the San Joaquin Local Health District for o permit to construct and install the work,herein+ `+ described.This apphiation is made In compliance with County Ordinance No. 49 and existing Rules and Regulations:,-:.;a,� JOB ADDRESS/LOCATIO .�O �1 ...... ... .... . ....................CENSUS TRACT . Owner's Name I �.. },; f .. ... .. ........ ... _.Phone f '{ •: Address ............. . :. Q.... � � � city . .............. Contractor's Name .1. ..4t% 7 �-...._ ......License # ....... ................ Phone Installation will serve: Residence❑Apartment fiouse❑'Commercial ❑Trailer Court ❑ 1 1 Motel❑Other.....:... '� T g Number of living units:......... Number of bedrooms ............Garbnge Griner ............ lot Size dale Water Supply: Public System and name ........................................................_.........-.................................. Privets Character of soil to c depth of 3 feet: Sand J] Silt❑,- "Clay ❑ Peat© •,.Sa6d .Loam [] Clay Loam j k Hardpan❑ Adobe❑ Fill Material..... If yes,typo ...� M1 s t a f {Plot plan, showing size of lot, location of system in relation to wells, buildings,'"etc. "must be placed on reverse side y NEW INSTALLATION: [No septic tank or seepage pit permitted if public sewer is available within 200 feet.) 0: PACKAGE TREATMENT [ ] SEPTIC TANK[ J Size..............:.....'. ..:......_-. ' Liquid Dept!t ....................... Capacity ........... Type ...... Material.....:................ No. Compartments Q 1 Distance to nearest: WeII .......Foundation Prop. Lina ... ' LEACHING LINE No. of lines ........................ Length of each line............ Total Length ......................... +4' [ ] 'D• Box ............ Type Filler Material ....................Depth Filter Material ................................. .... Distance to nearest: Well ..... Foundation ........................ Property Line ..................... SEEPAGE PIT [ J Depth .. Diameter Number . ...... Rock Filled Yes ❑ No I❑ Water Table Depth ..Rock Size ................ D-stance to nearest: Well ...Foundation Prop. line r REPAIR/ADDITION{Prev. Sanitation Permit ............................................ Date .................................. 1 Septic Tank (Specify Requirements) .......". p IP Y q _ Disposal field (Specify Requir encs) .......... .................... 3 • f :r r!rrr... ..rte/C.... ..� ....- .�].. .rf}........`rvtL ... . .(r....l �.{lYi: 11.Ff L!.•�•G,--bJ� � u ,j' exryling nd required ad�i�on an r�vrj,e sI '/ pf ar 7j� h�Firyeihe wo;k v�l�ina_do • In ecce ann Son Jcagvin I �� 1 hereby certify that I have spared s applic t n o _- County Ordinances, State Laws, and Rules rand.Regulations of the San Joaquin Lo.al He 16 District.Home owner or [icon- 'f ' sed agents signature certifies the following:' , t,t 111 certify that;n the performance of the work far which this permit is issued, I shalt not employ,any person In such manner =`• as to become subject to Workman's Compensalion laws of California." Owner Signed ...... fv'�i.tl.. ............. Title ...... ..... .." .......... . .... C ....-.............._.. - .... j By" """ (If o than owner} } j DEPARTMENT USE ONLY i l• � .tet Yr�r S APPLICATION CCEPTED $Y ....... ... . ./� ..:4 .. ........................................................... DATE. ':. y..-� .............. f BUILDING' PERMIT ISSUED.. / . T 1 ' .. ....................... ADDITIONAL COMMENTS . ' 4 .rt k... .y� 1 r-..... .... .................. .. .......... ........ry . ... ar. J` .................... .........".............. ................................... !J ........................lJ"... ...,.� ITnape ionby: .........................................."......................................... ................ ......... •ate ............................................ Y yGl `ju+�•'�•rf ,rr-../ y AN LiJOA,�},INYLOCAL HEALTH DISTRICT/"`e'• ��•� � f��'+�� i 1 E.H. 9 1•'68 Rev. 5M V F i f i