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FOR OFFICE USE: t V*PLICATION FOR SANITATION PERI `,�,' `_J Permit No. ..................... . ...... ..... .................. - Complete in Triplicate) ?................. This Permit li Date Issued ..l�.'....:....... ! Expires 1 Year From Date issued Application is hereby made to the Son Joaquin Local Health District for a per to construct and install the work herein described. This application is mode in .compliance with County Or finance No. 549 and existing Rules and Regulations: _.S7 . 3 Gr1 _ _ CENSUS TRACT .......................... JOB ADDRESS/LOCATION ..... � t�,---._....u__, A......,. .. Owner's Name ......... ` C _ -• •--.... Address City Contractor's Name._ c:,:,c ` <+�--- ``"��``?��i' z�- ........License # �, , •-- Phone - / �7 Installation will serve: Residence ❑ Apartment Houseo Commercial NTraller Court Q Motel ❑edroom Other ' '-.,�---------------••-•--- X ---••----- _--- C� f II is � - : Number of living units:.-- • Number o s-ry�.Garba Grinder . -� Lot Size .... _ 1...... ...................... Water Supply: Public System and name ........ -----------•--•-•-.....------•-•-••..................Private ❑ Character of soil to a depth of 3 feet: Sand T:] Silt❑i Clay C:] Peat El Sandy Loam 0 Cloy Loam ❑ Hardpan ❑ Adobe ( Fill Material ..........._ If yes,type :........................... (Plot plan, showing size of lot, location of system in rel/ation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: JNo septic tank or seepage pit Frulttedif public sewer is available within 240 feet,}PACKAGE TREATMENT [ SEPTIC TANK I j X�`S ize................................................. Liquid Depth .......................... l Capacity -. Type ';-..........._...... Material...................... No. Compartments ................. d a . ................, ---------------------- o Distance to nearesh- Well .....:............ ............••Foundation ..... Prop. Lin LEACHING LINE ? No. of Lines .._---_ ............r11 Length of each' line...... CI ...... Total Length ..............01 D' Box ' Type Filter Material ,pD.�a .....Depth Filter Material ....__ r�...-..-.�-•--••-•-•- Distance to nearest: Well .. :.. tZ��t Foundation ...le.._.......... Property Line ..: ...............� Diameter -? . .. Number Rock Filled Yes Na Q SEEPAGE PIT [ ', Depth ........ Diameter �:._...... ................. t ..� Water Table Depth ....... :...... ------------------Rock Size . Distance to nearest: Well .... •• 1 --........Foundation ..Za......... Prop. Line ...5...............10 REPAIR/ADDITION(Prev. Sanitation Permit# ............ ........................ Data ySeptic Tank {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 clone 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 -��- ,per- � tiC '= '�......... ....._... ByC. ..cam... ��...—.. -----• Title ......._..C�C'r........ . Y (if other than owner FOR DEPARTMENT.. USE ONLY APPLICATION ACCEPTED BY .. ......................... ..._............. DATE .._......a�.r�...•••.•.•-•--• . BUILDINGPERMIT ISSUED .. ................ .............. ............................ DATE ...................... ADDITIONALCOMMENTS ...................:....:............---•---•--••....--- ..................................................:...................... ........................-..................................................................---------..:--•--........---------------------................-----.............• „ -- •--..........._...........................................•-•---... . ................................... .... O..Final Inspection by. --••-- ................•----......:...................................................... -- SAN JOAQUIN LOCAL HEALTH DISTRICT 7/72 3 ME. H_13 24 1.'68 Rev. 5M