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FOR OFFICE USE: • APPLICATION FOR SANITATION PERMIT – �3 ............ 's., �� --.....--•- ......__. Permit No. ..�5..�_ ....... J 4 • M a 1Complete in Tnplicafe) f3 Y7 ....... .... as 7S, 4� This Permit Expires T Year From ate issued Date Issued .................... Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein I described. This application is made in corn fiance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOCATIO ----------- ........... .. ................ ' ....CENSUS TRACT .......................... ...... ..... one Owner's Name .-•.............. Address ' *. ..:....... ... . .... ..._.. .. .. _.. :.._ .... City --._...-----........ �G -��a77 Contractor's Name - -S ._.License # W....- Phone ..................1._...._.... . --....-... . -tom'--------------- l Installation will serve: —Resider�ce�Apart hent House-,�.Commercial,.❑Trailer_Court[] Motel ❑ Other -------- - ----------------------- ---------- Number of living units:........- Number of bedrooms -.3......Garbag�-Grinder`r............. Lot Size ................. Water Supply: Public System and name ...................._.--.----.._..... ....... - ---------- --•--------- Private © W Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ r Hardpan ❑ Adobe Fill Material .........�. If yes, type ..__.I. .................. (Plot plan, showing size of lot, location of. systemin .relation to wells, buildings, etc: must be placed on reverse side.), NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewerlis available within 200 feet,j PACKAGE TREATMENT [ SEPTIC TANK ] Size............................:........*...... . Liquid Depth ......... Capacifiy .. .. _. ..... Typed ------.- N4ateridl:"* _.t. ••'- No•^Compartments ------------- Distance Jo nearest: Well,' ..__.. .:...........:......Foundation ---.__._...._._...... Prop. line ----------...........1" LEACHING LINE [ ] No. of Lines :_.. length of earn-line : ` Total Length It - i .. ._.._ D'Box ..-... ..... Type. e Ful,ter Material ..---_—..!��Dept,h.:,Fdter Material ------6------•------ ----------------------- Distance to nearest: 'Well .. ............... _ Foundation ............... Property Line .__......._.-------- SEEPAGE PIT [ 1 Depth Diameter .___ ...---."?sfumber _...... !. ............... Rock Filled Yes ❑ Na Water Table Depth -__._ ......................Vm-Rock SizeJ.. �n .....--.---- ---•-- III Distance to nearest-W611 ------------------ .----._._-.---:Foundation __..;----•._ ....... Prop. Line ---------.---- REPAIR/ADDITION IPrev. Sanitation Permit# --------- -:-..-----..�.-- Date �g:��.......... �--�--f-�-•-•-••--! -+ Septic Tank (Specify ,Requirements) '- - .-...�. 4LlX::c .'t�c° `''' �' � .."°"ti ... �! •' .• Disposal Field (Specify Requirements) ._. t -Z— - a' -••�� = k : .. ......................: rn++—e:......-._.:.____.....�� _.....a...__....4 _ .�,+•.+�.......�i _.___.-.v_S1 _ ..._...._........__...._....__...... .............___._..•..___.. ... .............................. .tet.... ...... ... ..-..._. --•................... ......................................................................................-..--------._.._....._.-- .._.....__...... ........------.•-------.__...._...____• (Draw existing and required addition on reverse side) I 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 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 r9lanner 1 as to becomeisubject o Workman`s Compensation'(ws of California." Signed ..__ . .. --.. _ .... -----------------------------------•----- Owner . •--• Title . .... �.�...... ... #(If o ner) a I FOR PART ENT USE ONLY ' + APPLICATION ACCEPTED BY ---- � -' DATE �� J•-�--........ BUILDING PERMIT ISSUED...._..._.. .__.-:. ... ................... ...._.. `' :. ....... DATE . ............................-------...... ADDITIONAEk,COMMENTS~------------------- -------------------------------- ----------....._....._...--- d ................................... k ......_...------•• -•........................... -------- -•--.._........................---- ---- ---- - --.. ---------------- ..------•---------- .-.- �:::---- : ....... ----------------------- I. Final Inspection by: .....---- -� r ..N: Date SAN JOAQUIN LOCAL 'HEALTH DISTRICT _ d Ii 7172 F u 13 3 ,K