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FOR OFFICE USE: .. . .a, APPLICATION FOR SANITATION PERMIT - .- (Compie#e in Triplicate) Permit No. .7 ..............: -... •................ ........................... -----.---- , This.Permit Expires i Year From Date Issued Date Issued711 . Application is hereby made to the San Joaquin tocol 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/LOCA9,�..SQ:._ �C4zt..'.- E'. .ltM. �_ .....?!f'''! SUS TRACT ........ ............ TION •---- �: . . Owner's Name ................... . ..._. . ..._•-- --•-�..j'---•-•--...-,---.---...-..... ..... ..Phone .... d ......... Address .................�. . ..:........ .. �3-..._......... City -------- -- - Contractor's Name . - ................License # �`_7' �_ Phone?'��.... ...� y,...�..... Instollotion will serve: Residence i Apartment House Commercial ❑Trailer Court 0 Motel ❑Other ............................................ r ' Number of living units Number of.bedrooms.__. ....Garbage Grinder .-... _ --- of Size ..5;10 Y\ ............... Woter 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 0 Fill Material ............ If yes,type ............................ (Plot- plan, showing size of lot, location.ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic sank or seepage-pit-permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK r Size.......J� .......... Liquid Depth .......................... Capacity/ _�- Type p --- _ Material__�-G- -- No. Com artments ..�........... Distance to nearest: Wel$ _---•-------------------------Faunc�ation .._l.Q..f..-_•_-._ Prap. Line :.5...�. .......... I LEACHING LINE No. of Lines -.-.-._�..... ;Length of each line 'sa`. :�....... Total Length Y D' Box Type Filter Ahaterial -- --- ---- ----Depth Filter Material ....../.. ............................ S' DO \ S , Distanceto nearest: Well -_-.... Foundation ---f_U...�_.------ Property Line _..---.....'........:.... cq� s Depth a--- Diameter �� : Number ....... �•........... Rock Filled Yes g No Water Table Depth ...4&t: ............•---------Rock Size �.---�-•---•�- -- 1 - r ami Distance to nearest: Well -__--___..__•........................ Foundation ..f.�_.f_-.- Prop. Line -s_.__._•----_-.... REPA{R/ADDI ON(Prev. Sanitation Permit ._. .... .......I.. ... Date ± I rn Septic Tank (Specify Requirements) ..................... ................................................................._...._....___..-..-•-----•...---•- ...... r% Disposal Field (Specify Requirements) --••------- -----_-----------•--------- .-.-.-•-----•--............................................. ..:..•---•--- a --------------•-------...-.--...------------'...................................................................................................................................-•-_-_............. ...._ 5 ............................. ---••--•-------------•. ..-----------•------.-_...._---........----....-..-....._....------------------------------------------ --------- ----------------- ----- . -------- -_------- t- (Draw existing and required addition on reverse side) ; 1 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 owner or Hem 0 sed agents signature certifies the following: 1 "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.V— --�— ---- Signed ...... •--•.......... . ....... ' ....... Owner 1 �1 --- Title (If h r than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .--•- _-...•.. ...................... DATE ,....--.5 _...�_,.�......... BUILDING PERMIT ISSUED .................. ._DATE -:.-..... .............. ------•....................... ADDITIONAL COMMENTS ----------•--.-.............. _. - ------ ---------------------------------------•---------------....._........._................----....•----•-••------.---..----•-- -•----•-- - - i ------ ------------------------------------------- ..............by _ -.�.... ., SAN,JOAQUIN LOCAL HEALTH DISTRICT f E. H.13 241-'68 Rev. 5M 7/72 3 X