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a` R FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT ------------- ----------- .------- - . ...------ (Complete in Triplicate) Permit No. ..�3:-%v3 ............... i f... ... ........4 _.!._.._............._....-- This Permit.Expires 1 Year From Date Issued Date Issued Applicatiori'is hereby rnade to the San Joaquin Local rHealth District for a permit to construct and install the work herein I described. This application is made in mpliance with County Ordi nce No. 549 and existing Rule and Regulations: �7� �-� 6� r � __ � _ � .` ..1.. ��...__. �5L15l�ACT ..�f..7..:.......:--- JO ADDRESS/LOC TION ...: ..`... .� a .Owner's Name .... 1... 1t Ph ne � .... r •• •• . 71 Address .............. .......... ... . ..... /17 r .fes.. :_._.. C' Y . ... � • .. Contractor's Name .. ....... ... ..--`-.-- License # .��= � Ph ne „�-_ . ----- ....-••...... .._. ..... x Installation will serve: Residence, artment House-E] Commercial ❑Trailer Court 0 I� Motel ❑ Other ------.............:...:":.................. Number of living units,............... Number of bedrooms------.Garbage' Grinder . _.... Jt- Si. . _. Water Supply: Public System and name ..........................................................--...----- -------------1---- .............. ........Private Character of soil to a depth of 3 fest: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ i Hardpan ❑ Adobe N-1-IrMateriat Imo.. If yes, type ------------- -----------•-• - . + (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be plo6d on reverse side.)'"-` ' NEW INSTALLATION: (No septic tank or seepage pit permitteA,if_public_sew.er is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK �.+ Size._._...! �� .... liquid Depth _.... &- Capacity .�� ..... Type .. Material. _ �.to. Compartments .:... ....._ once to nearest: Well .___ /_6n " Foundation .. ..•r--_-_-•- Pro` p Line ---•--..._ ............. r LEACHING LINE [ No. of Lines __ ^-- ------------ Length of ach fine..D�}_ ' _ .....#.. Total Length 1W............... F D' Box/to _ Type alter Materialjff. Depth Filter Material ' Dista nc nearest: Well ........... Foundation _. d..-___-- -. 'Property Line ..t'`�:................ SEEPAGE PIT [ - Depth _._:•___._. Diameter 2 ...... Number _-_____ Rock Filled Yes I� ryo Q Water Table Depth _.....-/--. ...............................Rock Size ...�_�:.k..�.!_.. rl Distance to nearest: Well ---r---- ---------- Prop. Line -fid..._______..-__-•- REPAIR/ADDITION(Prev. Sanitation Permit#.........-................................... Date ..................................I i Septic Tank (specify Requirements) -----�...........-----------------------------------------------------------------•-------------•---.....................-.-•---------•--•- DisposalField (Specify Requirements) ----_------- ----------- -------------- •----•- •---------- ------•--_----------- ----•----- --------•-•---•----------------- -••---•-----------•-----•--•-•--•----------------------- ------------------------------------ ---------•-----•- ..............................-....................._......................... _______ f" (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: ,. "l 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 � 0 By •................. ..... -- ... Title ....---- .. _..._.. ..�'� . (If oth r than owner) FOR DEPARTMENT USE ONLY ../....•--- =�--------------------- DATE ....APPLICATION ACCEPTED BY j .....�...BUILDING PERMIT ISSUED ........ ................... �...... DATEll:.... .Z��._....._... _................. iADDITIONAL COMMENTS ........:...........................:............................................. ------------------------..........._....._..... ............ I ...........................................•..........................................................................._......---•-••----- ............ - --------- -- -- ---------------------------:. -------- ---------------------------------- ------------------------------------------------------------ -------------------------------------------- ------ --- - - - - Final Inspection by ...Date . '? -SAN.JOAQUIN LOCM HEALTH DISTRICT _ 4. r 4.r 13 241_-A;t batt 9;AA 7172 3 M