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fOR OFFICE : 4 � '- APPLICATION FOR SANITATION PERMIT ft 7S �/�3 ....... ..�_.... _ (Complete in Triplicate) Permit No. ..................... 3 3 � -•--•-----------•..................................------ This Permit Expires I Year From Date Issued Date Issued .._..:....__..7S .... 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:: JOB ADDRESS/LOCATION ................. 3 .-.__. . �� .. ..... ..........................................CENSUS-TRACT f Owner's Name �4� v l I - ..__ _.....d-.t?. �7� G.�. aCaf. ..................Phone ©�s� Address _ . ----------•---•-. --•--...._.. City .. -.-__A :.. 7--P.4- ------------- -------------- Contractor's Name : �.t-], '�a �s.,�j...,(-:. ?'s=rine-:-- oar -----.License #p[ tfa . ... Phone .�, 0 Installation will serve: Residence]Apartment House f] Commercial❑Trailer Court Motet ❑Other Number of living units:......... Number of bedrooms Garbage G ander Eot Six r .� iJ....._�.l d Water Supply: Public System and name �f� -y— ' -.................. ��F�{Ct.�LirrL7.. .....i.............Private ❑ Character of soil to a depth of 3 feet: Sand Silt Clay❑ ❑ Y ❑ Peat Sandy Loam ❑ . Clay Loam Hardpan ❑ Adobe:❑ Fill Mpterial ............ If yes,type ... I (Plot pian, 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 sewer is available within 2Q8 feet, PACKAGE TREATMENT { ] SEPTIC TANK ] Size_....... ........................... Liquid Depth Capacity ---------- ---- Type -----___•_----_-._ Material-------.._----___--- No. Compartments _ v Distance to nearest:: Well -------_-_-----Foundation Prop. line LEACHING LINE j ] No. of Lines ------------ Length of each line.................• -Total Length f I D' Box ... Type Filter Material ___Depth Filter Material M Distance to nearest: Well ...................•_$_ Foundation ..__._....._.._.. ...... Property Line SEEPAGE PITDepth --------- .......... Diameter ------------- Number -_._._....- ................. Rock Filled Yes '0 .'No ID - Water Table Depth .................. .........Rock Size 3 Distance to nearest: Well ...•------------- ...Foundation -=.... :Prop. Line .....---..:..:-------- -L,..« i REPAIR/ADDITION(Prev. Sanitation Permit :___--_- Date _ Septic Tank (Specify Requirements) ...... ........: 1 .... . - � ........ . - .... DjosaZIFieldments �.(Specify Require ) ` / ' . -• •-•••--•--...._•--.••--- ..................................----------- ........................ •-•------•-- - t (Draw existing and required addition on reverse sldel I hereby certify that I have prepared this application and that the work will be done In accordance with Son Joaquin County Ordinances, State Laws, and.Rules and Regulations of the San Joaquin local Health,District. Hems owner or [icon- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit isissued,Fl shall not employ any person in such manner as to become subject Workman' Comp tion !a # California. Signed .__ - --- - - finer- . .... .. .. ........ BY ---•----•--- -_------•----------- ---- � :. _.._. Till ._.__._.._ (If.other than owned - ----�....----------------•... _= FOR DEPA ME T U E ONLY APPLICATION ACCEPTED BY _. BUILDING PERMIT ISSUED ---------------- DATE `��.:.. ��_._ ADDITIONAL COMMENTS ------------------------------------ DATE .:.................................. .............. ...... •---................. ..................................................................................... ............. . .......................................•--•----.............•....—.... Final inspection by: .......� . .................. ... -•--- .Date ..:. .._. ... :...... -- ... . ..............-- SAN JOAQUIN LOCAL HEALTH DISTRICT AdL