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_FOR OFFICE USE- ' `2 APPLICATIC3N FOR SANITATION PERMIT I {Complete in Triplicate) Permit No. ..7./.._,_�"1y f 1 ' This Permip4pires 1 Year From Date Issued Date Issued ._...... t/ - t 2_yS•--0(0 30 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This.application ' m .f in compliance wi County Ordinance No. 544 and existing Rules and Regulations: 108 ADDRESS/LOCATI N ..... ... CG 4_1k,44 .........CENSUS TRACT ...-.5�.= ..... Owner's Nome •- .Phone .................................... Address • „. -7 • y .................................J.._......_._...._.... Contractor's Name ........... .... .. ......License # ... 'dam '�' Phone �Q-�... insta!)atin will serve: Residence [j Apartment Muse,❑ Commercial ❑Trailer Court 0 Motel ❑Other/ Number f living units:.. _.. ..... Number of bedrooms .._ bage Grinder ........ .. Lot Size .. .... ,, Water Su 61y. Public System and name _._.... ._�.._.._ ^. ......... ..._..,.:_._......... .....c_._.._......._..-•-- •--.... ....Private eh_a_oder of soil to a depth of 3 feet Sad Silt Clay.Y i � Y ❑ Peat❑ Sand r Loom� Clay Loom Hardpan,0 obe f7 Fill M'bterial .._... ... if yes,type ........ -�-. (Plot plan, showing size of lot, location of system in relation to wells, buildings,-4tc must be placed on reverse side.) C) NEW INSTALLATION (No septic tank o�r�selej5o'ge pit permitted if 6lic: sewer is aailable within 200 feet,jPACKAGE TREATMENT [ } SEPTIC TANK I ,ze........ .... . ... ......... ...... �liquid Depth _..0�-1�.._.......... . Capacity� 1 r ... Type . . w '�G. .. No. Com aftMehts ...................... �.► t .-rp , Distance to nearest; Well .. _..t`.. :.._....:.Fovndation_../fj '�- pYrop. L-ine LEACHGLINE No. of Jotal Length length of-each line..-..... .� .._._-.--_..... .. Box...... Type Filter Material f1 .De th Filter. Mater a. _ P p-. 1 _.. . . ........ Distance to nearest: Welt ..f..(}�._ ....... Foundation .../.0.J., - Fbperfy Line .. . . SEEPAGE PIT [ ] Depth t.,.,. --' Diameter ................ Numbe . ._.... . ..... .........__ Rock Filled Yes ❑ No ❑ —EraSM Water Tobie��ppepth ..................... ... . Rock Size ...__. bistance torriearest_Well .._........0..... . .......... •:.._._Foundation........... ........ Prop. Line . REPAIR/ADDITION(Prev. Sanitation Permit# .....................`......_.... .......... Dote ......... ptic Tank..(Specify Requirements) .. n i r �y f i'posat Fie d (Spec,fy Regviyemgnrtssj U ...= "��':+r•x•:r.'rsr..2::::ek� M{-�''��, n.::•: ....•�!.,�r:i-;.�•--;. ............._.:_.._„'�!�`•'!�'!�7.�.. •e.._.: ....,.4W.r,�-"w�'.JtJ".!'..._.........:...... .................,:.... (Draw existing and required addition on reverse side) i tererby certi i irha ,i?i v`e pr pared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Lows, and Rules and Regulations of the San Joagvin local Nealth District. Horne 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 subiect to Workman's Compensation laws of California." Signed . .. ............................... .. Owner' By _, `.... . Title . .... (Ifo er n owner) -_�._< FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYt, DATE ....- .. .f.✓.. _.l, ...... ._. ....... .. ....... . ................. BUILDING PERMIT ISSUED __ DATE . ... .. .__-. ..:.................................... ............-. .-..__....... ADDITIONAL COMMENTS ........... .. ........• ... •. ... ............................................................................ ---.._. Finallnspe ...._.... ._Date SAN JOAQUIN LOCAL HEALTH DISTRICT E..H.13 24]-'68 Rev. 5M __ 7/723 ,K