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T FOR OFFICE USE: - - `:.PPLICATION FOR SANITATION PE,:; IT (Complete in Triplicate) Permit No. -.` ._.._€ a .. .. .... .--_...V:.........,,_,.-f„_ This Permit Expires 1 Year From Data Issued Date Issued ..fF.�i9-.75, Application is herhby 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 ... ��..;- .-t � �t ..... �......................CEN51�S TRACT .- - --..._.... Owner's Name :...... `."...:........ ' f.............•----------_ •----------•. ------........Phone .................................... Address City -.. . .................................... Contractor's Name s.�a..... t om'`� '!fS:..._. ':C:'--'---.License # /,F ..hone .............................. .. ff Installation will serve: Residence(Apartment House 0 Commercial❑Trailer Court 0 Motel ❑Other ---•--•------------------------------------- Number of living units ._.. Number of bedrooms ....yGorbage Grinder ............ Lot Size ......4:�--��:_ Water Supply: Public System and name ---------------------------------- ---------------------_........._.._....._...--------------------..........Private Character of soil to a depth of 3 feet: Sand❑ . Silt❑ Clay ❑ Peat❑ Sandy Loam e Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ...........................• (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 public lic e/ 67wer is available within 200 feet,) , J PACKAGE TREATMENT [ ] SEPTIC TANK Size_ a .................. Liquid Depth .................. Q a fgz_ . �N Capacity g .. " Type ri✓r. ...a-___-- Material.._t?'._tr:�?...... No. Compartments ....... ....... Distance to nearest: Well .............r'._i;V- `____---Foundation -....rrrl!,,(�"�: Prop. Line -----_; � LEACHING LINE [1J No, of Lines ......r�------------- Length of each line.___.,_ �__'....__..._ Total Length ...14�•. ------- 'D' Box ... : :___ Type Filter Material S.e .......Depth Filter Material ........1.!.............................. Distance to nearest: Well ------;�� _ Foundation _._./_Z .__.._. Property Line _... . 1 [ Depth Number .......L................ Rock Filled Yes 1!r No Q ¢ SizeWater Table Depth ..................Rock r2• �3.. ,.. Distance to nearest: Well ......1141r'��_______________Foundation Prop. Line _._. REPAIR/ADDITION(Prev. Sanitation Permit# -------- ........ Date ........................ SepticTank {Specify Requirements) --- •.............._-----------------••---------------- ------•----•--•-----------•--------------•----_-_•_............................... Disposal Field (Specify Requirements) ...................................... -----------------------------------._........................___.------- --------_---------- ..............................................•-----• --•-•----._.._......................------------------------------------------.....--------••-----••--------•--------------------------- (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 agents signature certifies the following: "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 Workman's Compensation laws of California.” Signed ............... ..... .... �: Owner By ........ ...............j ' , `f '�!.-_..._._ -:.... Sitle ..... ....................... (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ............... .................................................... ------•..•. DATE _c +.. _-.fir ................ BUILDING PERMIT ISSUED ... ... .......... ............••---••-•-••--•-••--...___........_DATE ........................................... ADDITIONALCOMMENTS .................................................................................... ................. ........................... ----------- -------------------------• ............. ...-.......................................................................................................................... ....... Final Inspection b ,. ....................................-----........-----•...._..__..Date . :1 :. ..................... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 1-3 241-'b8 Rev. 5M 7/72 3 M