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FOR OFFICE USE, APPLICATION FOR SANITATION PERMIT ........................................ .... Permit No. ._.7. '- 33 t (Complete in Triplicate) •.............. .----------------- ............... This Permit Expires 1 Year From Date Issued Date Issued �.' p.::�� Application is hereby made to the San Jooquin Local Health District for a permit to construct and install the work herein described. This a plication is made in cQmplia ce with Count Trice No. 9 nd existing Rules and Regulations:�{ �.t -7JOB ADDRESS/LOCAT .. ... .... .. .:.. ..` ........ CEN5US TRACT _....._... Owner's Name-- ;.,._ _.-1.`. .. .... • .1 .. .....-•-•........................... ............. ....Phone �_ .- Addrei . .... .��'._�.... 0.t- City ._ r .. CitY ��IQ��`1 Contractor's Name > +�'.... c ��I _....------License #aZV7J9Z Phone 7.-�. gve, Installation will serve: Residence Apartment House❑ Commercial []Trailer Court ❑ Motel ❑ Other ......:. ....:......... --------_. TK _ Number of living units-......... Number of bedrooms .._ arbage Grinder tot Size .1 �.-...-•-••.-•. Water Supply: Public System and name -...................._............ .................................................---.........__..........Private Character of soil to a depth of 3 feet: Sand Silt❑ Clay E] Peat❑ Sandy Loam Clay Loam ❑ - � d—`Haraabn❑"Adobe ❑�il?Vlaterial^" .... If y ;7' estype .._ (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 ov '}able within 200 feet,) PACKAGE TREATMENT [" ` SEPTIC TANK t ] Size.__...1-. Q_.. f '' ._____. Liquid Depth .......................... Capacity .r -_.. Type . �� ter. Material............. No. Compartments ...4Z_- 1......\ Distance to nearest: Well ...................Foundation ®........... Prop. Line LEACHING LINE [ ] No. of Lines .._ Length of each line ......../.0.......... Total Length �.�--7.�-__-____.-. �} 'D' Box ,- - Type Filter Materia..- --! ...._Depth Filter Material ......1. 2_ ............................. -f1 Distance to nearest: Well _ Property Line �. -�-.-_-..-- Foundation _..��-._._. ... Proper ------------- - r SEEPAGE PIT [ ] Depth . . .. ........ Diameter ........ ....... Number ._ ..... Rock Filled Yes ❑ No Q �. ` Water Table Depth ...,.................I............------------.-Rock Size ................------------ M s Distance to nearest: Well _..------------------ --.---....Foundation ............ ....... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation-Perm it•# __-----._---. .......... -- Date ------ -------------------------_ i Septic Tank (Specify Requirements) ........................ ------------------------------- _ el Disposal Field (Specify Requirements) ...-------------------------------- ------•------------------- ------------- ......................... ................. I - - - - - --------------- ------------- -- (Drdw existing and required addition on reverse side) S 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 Son Joaquin local Health District. Home owner or licen. I 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 beco ubi t t a1N man' pmpensati aaysof California." Signed .:.. ,. ... .. .... ....... .......................- ..... • ....... Owner d.-•...................... .... ........ Title . ..../� .. ... .............._..........._.. other an owner] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. .'.-......... DATE _.: �.... a--.7..�.._•----- BUILDING PERMIT ISSUED .................... ..... ---•---_ --....DATE _... ................................... ADDITIONAL COMMENTS ------ --------- ---------------- .-------_.-------------..."._........__......------....----=--- ---............ . --------- • •-...- ............:..._......_..---....--- ....------ -•--- Final Inspection by: ................. . y i ----------------- -•--------..._......---- Date ... .d 'J........... SAN JOAQUIN L"' HEALTH DISTRICT a. f c u 13 24 ,- :a n.:, 9A :x/723 x ]