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FOR OFFICE USE: ............................. ...... APPLICATION FOR SANITATION PERMIT : (Complete in Triplicate) Permit No. . . ..._"`. __-- .................................. _.. �. t .. Date Issued . This Per ....... Expires 1 Year prem pate 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: JOB ADDRESS/LOCATION ....... . . .....................F-C.:.... t ................CENSUS TRACT ......... ................ Owner's Name ........TH.0 A(,)Cj12.A�......�.- �LI1f ................. 4�, a.�.'..fi l.'� -..-•- .................................................Rhone .,. .. Address . 8 �.. :... - ...... ................. ........... City h ....... ...... Contractor's Name ----------- --------- (p?1L512�R-._----_- ----.............-.............License # ..........I.............. Phone .............................. Installation will serve: Residence Qg Apartment House{] Commercial QTraller Court C] Motel Q Other .........................:.................. 1 Number of living units....__ Number of bedrooms Garbage Grinder ...." .... lot Size ...... .................... Water Supply: Public System and name ................ ......... Private Character of soil to a depth of 3 feet: Sand Q Silt Q Gay Q Peat❑ Sandy Loom a' k Clay Loam ❑ Hardpan Q Adobe 0 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 seepage pit .permitted if public sewer is available within 200 feet;) Sky PACKAGE TREATMENT [ ] SEPTIC TANK Size.. { .........._ Liquid Depth .29_12L.*............... +�,� i t Capacity _�.' (9C? •[ Type :1. _ .1:_. Material..: _t4...___ No. Compartments .......Z-........._ Distance to nearest: Well --.---110.....................Foundation ...-la...........:.. Prop. Line ....a`Z............... . LEACHING LINE [ ] No. of Lines ..........t---........ Length of each line...-...... �.�............ Total Length .._A s.0 0 4� t� 'D' Box Type Filter Material 5epn%S:..Depth Filter Material ...........................1 �4� D-istance to nearest: Well ....1:1 `............ Foundation ...-_2d............. Property Line ..Ji.b............... SEEPAGE PIT [ ) Depth --------------_---. Diameter --............... .Number ._._..._._........_._ ...... Rock Filled Yes Q No (:3 Water Table Depth --------------------- --- . ......................_Rack Size ..'.._..---------.._........... Distance to nearest: Well ------------•-------------- --- ---Foundation r._._...... ......... Prop. tine ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .....___...... .................... Septic Tank (Specify Requirements) ................... --------------------------------------- Disposal --------------------...--------------Disposal Field (Specify Requirements) _____________ _ _ _ I ------------------------------------ {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 ;k County Ordinances, State Laws, and Rules and Regulations of the Son Jaaquirt 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 becom ct to orkman's omp ns tion laws of California." Signed -- - -- --- ---- Owner By ----------------- =------------------•------------------------------•------------._...-------------._.. J•itie .....-............... . (if other than ownerl FOR DEP LY APPLICATION ACCEPTED BY - - --------- _ m w -. DATE,..:::L'.-c : , ...< . BUILDING PERMIT ISSUED .. ...._ - ---------- ---- ------- DATE ADDITIONAL COMMENTS ---------------1.... ..............•---•---------... -------- -------------••---..-_--------- ......•.................. ............ --- _ finalInspection by: __------------------ ' - - - ... ------------------•-----------•--•-----•--•-•-...-•--�•---•---•- •---- _._..Dake -.....�.L .�7�.....---------...--- .._. EH 13 21a ' v. SAN JOAQUIN LOCAs*�HEA'LTH TI2iCT 8/7 L.