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F � FOR OFFICE USE: // 3 a--.-_ /APPLTCATIOWOR SANITATION PERMIT / '� ro. .73-.7./.. �. y�4 . . ...... „Permit No:•... ... .... !� ;Complete in Triplicate) y- ......................................................... : fDate Issued .-e-�-- . .3. .......................... This Permit Expires 1 Year,From Date Issued 2, tom, 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: s JOB ADDRESS/LOCATION .......................................................CENSUS TRACT .•............:.--- Owner's Name `. �_.. Phone . , �'f.............. ...,. f ,,� I Address ,.-�.��..-. .....- --......... City �i 4 _ .............. i . Contractor's Name ..__ _ f� � r----------- --------`......--....-.....License # Phone �� . Installation will serve: Residence Apartment House C] Commercial ❑Trailer Court 0 Motel ❑Other .........L........ ——.................. fi3. Number of living units:..-..... Number of bedrooms .......Garbage Grinder .41®_._ Lot Size A6<.I.�e4.4.............. Water Supply: Public System and name . _.. � _it Ate—A!ti✓�.`.............. .Private ❑ is ....---• ... Character of soil to a depth of 3 feet: Sand❑ - Silt❑ Clay ❑Peat❑ Sandy Loam ❑ Clay loam ❑ Hardpan ❑ Adobe 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.1tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENTS { ] SEPTIC TANK ize r �`'`� ... {............ . Liquid Depth { }. . Capacity/Ar4 ....... Typ es. ..... Material ... No. Compartments�.I, ........:..:.....� X r, k Distance to nearest: Well `'"" ..Foundation, .:... Prop. Line ..,9... ,......0 •LEACHING LINE No. of Lines ....... ............. Length of each line.... A ..........}Total Length .0�>e........... W i7' Box __ Type Filter Material Depth Filter Materia! G�.`...........................!._...� I k Distance to nearest: Well --------------_____...._ Foundation : ............. Property line ............. SEEPAGE PIT j Depth _...._.... Diameter _-..____ Number __Z.........:------------ Rock Filled YesA No 0 (� Water Table Depth -----------•--•-----..._ Rock Size`. ._.-.-_----- Distance to nearest: Well ________________________________________Foundation ._t,?ry�. ._ :. Prop. Line . ...... REPAIR/ADDITION(Prev. Sanitation"-Permit#------ ---.---: - .- Date-...___... _ ------------- i y kSeptic Tank (Specify Requirements) --••-----•----• ----------------------•-------------------------------•------------.•---------------_-.---_----- ........... ...... Disposal Field (Specify Requirements) ...............................--------•--------------..------..........._._.:..................................I....... .....__ ------------------------ -------- ---------------,-------.------------------ -------------------------------------•.........................------------------------------- ........................ { ....................................-..........i.._..... ----- ------------------------ ---------------------- - - .......................... .. J (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Lawn and Rules and Regulations of the San Joaquin Local Health District. glome owner..or..iicen. 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 become subject to Workman's Compensation laws of California." :L i Signed ..................?' on '------- - ---. Owner By .'. 'Title �� •.--•-•.... .......... ,..r� (If owner), FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .... ......_ . ..--..;.................................. DATE .... BUILDING PERMIT ISSUED . . .. ---------------•-•------.:._.-..-------------•----....._:...--••----•..DATE ..........--- ............. ...... ADDITIONAL COMMENTS .......................................................... ............................................................... ............................................ -----•----• ..............-.._...-....................... ............... .. ...............•--._. ----_-----------------------I................ --- ------------ .-------------------------------------------- ._...... --------------------------------------------- . ............ ........ FinalInspection by: -- ----------- t :.............••--...............................----••-••--•-------•------••-----------.Date ...... _._...�� SAN JOAQUIN :LOCAL .HEALTH DISTRICT CAo�r- N 13 24 1_-rn Qo,. qe,► 7172 3 M