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FOR OFFICE USE: r .i APPLICATMN FJ.R SANITATION PERMIT permit No. .................................................... (Complete in Triplicate) S7Y,._...................................................... 1 This Permit Expires 1 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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 1.. ........ .,�CY:.... a.. r.�...:FCENSU5 TRACT JOB ADDRESS/LOCA N'.:. . ._._a... 1.. .. �w Owner's Name :.... . . .......................•.Phone ..�C71-:7.l�.�..2r Address .-.. --�`•'•J- - -..._. �:.-.__ � City ..,... ....... m A. License # •-----------_..:._.----- Phone ...:...................:...... Contra'ctor's Name ----4 --etr �p - - 1 b� """r tet... :... .. :... .:... .•-- -•• - - --�.. -" -"- -i°- Installation will serve: Residence []Apartment House C] Commercial [']Trailer Court �► u�b #0k)/•r) ' ..Motel D Other Number of Iiving;.u.nits:........ Number of bedrooms .....Garbage Grinder ------------- Size .. t_,_ .................. Water Supply: Public System and name ......--•"""------------------I.....----•---...._..__..........-_..._......-• .....--••-•-- ........- ._._.Private ^� Character of soil to n'depth-of_3;feet:�San&o- -7Silt[]--Clay•[] Peat[} -Sandy Loam_. Clny,laam„D r Hardpan ❑ Adobe:0, Fill Material .......v.... If yes,type ...:........................ Its (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 seeps pit permitted if¢.public sewer,is.a�v-aiilable within 200 feet,J T21, ! ,- PACKAGE TREATMENT [ ] SEPTIC TANK, Siae:..�l_ y •�t�-- ,!-.!7 --- Liquid'4epth_" �.�:1 ...:.... 7 _.._ Capacity _ J...: Type ...Y�--=M aterial.::.. __Q�it-G--[.. No. Compartments ......�-c:..:.r.... . ` .. --_..... ( istance to nearest• Well Foundation ...' .C'J_....._..... Prop. Line . :_� i . LEACHING LINE No. of Lines .. _3. _. Length of adr line------• - ----.. 3..--. Total Length ..,�j :Gi....:......... 'D' Box Type Filter Materiel y r� � h Fllter IVlaterial '`_:_:_ :��_..:-.--:.-....:. . _ : . �^(?_._.. .... Foundation ....�D_.`�•`.._..-_ Property Line Distance to nearest- Well-..... •-•-- ------------------ SEEPAGE PIT [ J Depth .... Diameter __...::..--•---- Number ---- �::_..... Rock.Filled -Yes [] ',•No.�C3 Water Table Depth -----•-----••...........:........Rock Size -"--.:_......•-----•-•..._-•...... -. '. t Distance to nearest: Well ._.Foundation .............._.. .Prop._Line -".."--:---.-- ....... REPAIR/ADDITION(Prev. Sanitation Permit# .................... Date ................................ Septic Tank S eci Requirements) -•"•..... -""""" i . '... - --•----• Disposal Field (Specify Requirements) -_...___._. ...... ........................................... r.:.---. ---- ------- - - ------ ---- -- - - ------------ ---------------- [Draw existing and,required addition on reve-rse 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 ownee'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 be o ubject to W64mau s mpensation laws of California!' Signed .._....... :- _--•------•-- - Owner r If other than owner - . . . Title ....... ...::...........: By .......... ....... . .-. .....__... EPARTMEt4T USE ONLY APPLICATION ACCEPTED BY ... .......................................... DATE ..., ':. r� --............ - BUILDING PERMIT ISSUED ...... .. _ " ADDITIONAL CPM g T Isr+4` a-.7-�a _74 Final Inspect oi'n by: ................ ...._._......... r SAN JOAQUIN LOCATE}rHEALTH DISTRICT t L, 13 24 1_�ko De., ak 7/72 3 M