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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. .�. 0 This permit Expires I Year From Date Issued Date Issued Application',is hereby made to the San Joaquin Local Health District a permit to construct and install the work herein I� described, This application is--made-an-compliance with County Ordinance No. 549 and existing Rules and Regulations: iy _ r JOB ADDRESS/LOC N:J_�,.a ..... .... ----C .... .--' ... - . CENSUS TRACT :.:...................::.. Owner's Name .. — ''---- -------. x i . .. .- ..- .._ . ... �.._ .. zPh q . .. ? Address .._....... City . .. / rr�. _...,1.. .476 -7..................... Contractor's Name ..----..License # ..�.�'�.3..�.�.�Phone ........ .. Installation will serve: Residence Apartment House❑ Commercial []Trailer Court 0 —Motel [3 Other ......................... Number of living units:.... .1,.... Number of bedrooms )_....Garbage Grinder Lot Size ......_._................................. Water Supply. Public System and name ......------------------------ ----•- ... --------------------._._................................ .........Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ 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 see age pit permitted if public sewer is available within 200 feet,) u I PACKAGE Tv0 R [ ] IC TANK T7 size.. .. X1 --..x_ .- ...__ Liquid Depth --iv._.�:.............. p TREATMENT SEPTIC fCapacity 1��. .-.. . Type Material_ a > ..... No. Compartments .... i : Distance to nearest: Well � �.. ,...-......Foundation ...Lv_ ....... Prop. tine LEACHING LINE [t� No, of Lines 3 --._ .- Length of each line ..:....L4.a. ... Total Length D' Box .-...� -... Type Filter Material ...... x..1.1-._--Depth Filter Material _..,_..).- .::.................... Distance to nearest: Well ---..:fir..{- _._._. Foundation ----- Property Line _. .,� .._._....__ SEEPAGE PIT Depth 3.3 ".... Diameter '-.-- -[. Number ..... . .............. Rock Filled Yes [Er' No Water Table Depth ......... �-�?-_..l.l?_a..-t Rock Size ...�.fa ..._._at... ...._. P Distance to nearest: Well .........1. ?. __. - .-- ---Foundation ----L.E7.. `... Prop. Line ----- �'....... 1 REPAIR/ADDITION(Prey. Sanitation Permit# -------- -------- � . ......................... Date __...:..__...----••-•--'--- ...... Septic Tank (Specify Requirements) ..._... ..... . •--------------------------------•-----•- ------------------------•-------•------- --------' Disposal Field (Specify Requirements) ------•--- ---_--•------••--------- --'....................•-•-- ......... ------------- (Drdw existing and required addition on reverse side) I hereby certify that I have prepared this application and•fhat 'the worse 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 _ I By .... . . . . ... -x-.-..,: :_..........:...�.._, z .L .:.. u- � 1itle - - .-._._.---�-�- .-- .. (If other than owner) FOR EPARTMENT,USE ONLY APPLICATION ACCEPTED BY ... _.�'.... � :'...: .__ .. DATE .. .......... BUILDING IN PERMIT ISSUED ........-: `_= ... ..... --'- ------- .-........DATE .............. ADDITIONAL COMMENTS .......................................... : ------------- .............. --. --- -' _------------ - ------- / Final Inspection by: .......... ............. .......................... Date .. Z.�?.'. C: SAN JOAQUIN LOCAL HEALTH DISTRICTi� E. H. ._ 1-=bB Rem,5ltA _ - - .. _T172 3 � " e A l � 13_24 � `