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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT ,�;.._,.:.. ........................... Permit No. _7171 �... (Complete in;Triplicatel ........................................ V 11. 1 .7...`ZC 7 V .........................................�t_.... This Permit Expires 1 Year From Date Issued Date 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. 544 and existing Rules and Regulations: n .c:`a I� JOB ADDRESS/LOCATION ..........�3. - :�.. `�C tit c.. ...:. . ............................CENSUS TRACT ....Y�.. Owner's Name --- -------------------- -- -- � ��1��t��g...........................••r--•--------...........................Phone til Address ------------ _. _..... . .... '�4..cant.-............... City ..........._._.....--•--••---. ............. [ F Contractor's Name ....... r, ..........................license # a��. •-7- 4�: Phone Installation will serve: Residence (Apartment House 0 Commercial ❑Trailer Court Motel ❑Other .............................. .......... Number of,Iiving units ......_N.umber__of bedrooms,. ____._Garbage Grinder ............ Lot Size . -.................. Water Supply: Public System and name --------------------• ------'--------.................... --------,............. ......Private � f` I Character of soil:to a depth of;3 feet: Sand ,.Silt C] Clay ❑ ; Feat 0Sandy Loam C] Gla Loam ❑ t �Ha�d an Adobe -Fill Mate al-'_--"�'If' es, a ......':......'_..----- ""� �'` P ❑ ❑ Y tYP N. �- .� (Plot plan, showing ,size of lot, location s'yOem`.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,j . 1 0 P PACKAGE TREATMENT, (,} SEPTIC TANK ] ;Size....�a �. _--------------- liquid Depth .._ ..---•-•---••- Capacity Type . ? , ? Material_ -- _ .: Plo. Compartments LEACHING LINE Not of Line's rest: Well ':..�e�I ..�f....q ..l�..._Foundation ...-- Q- ......... Prop. line . ............... 0 y 'S r K Length Re........TQ• -------- Total Length .. _�.�?............ D' Box ...:: .___ Type Filter,Material Q4 . Depth Filter Material �� r . Distance to nearest:.Well ... .._-•---..Foundation ..1 ............... Property Line .! .......•..:.:.:.:.- �4t;ti- ti SEEPAGE PIT ( j Depth ......Q1........_... Diameter ................. Number Rock Filled Yes ❑ �No.Q . , ` •' Water Table Depth ......:..........Rock Size Distance to nearest: Well ....... ............Foundation ----- .............. Prop. Line ......................p`' REPAIR/ADDITION{Prov. Sanitation Permit ti# ........................................... pate .................................. � Septic Tank (Specify Requirements) ...... � ---_.-----------•----------------------------= ----------- ........... r Disposal Field {Specify Requirements) . ---- ........................................... { ------------- ..........-----------•.......................................................... --------•--------------•----- ,__ �- _ ................. ` -= --- —..... ------._------------------------------------- ............. (Draw existing and required addlfionon"reverse side) I hereby certify that I have prepared this application' ..arid 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 Distritt. Home owner or licew sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become su ject to Workma .s Compensation laws of California." Signed -------._.. .. .......... . ............:........... ...................... Ownkr, y ................ . . .......... ......... ............................. BY •.............. 'e- ... .-- 4 Title .. other than owner) FOR DEPARTMENT MSE ONLY APPLICATION ACCEPTED BY ....- t� `r� .......---•....................... DATE ....2__.:L.-_7 .._.... BUILDING PERMIT ISSUED �. DATE •-----•--------• ------------------------•. ................... ................. ADDITIONALCOMMENTS --- --••---•......................_....\'..........................................-----•----•--- = ................. ......... •-•-- ------------- --- C . .... ----.................................... .......... ... ... ..... ...................._.. _ .. .. ._ . ._ _••................................... ........... ...............:...:•.. .------- ••__ - ..._.._........__E•-`Y�j-�-------•----------------•••-----------•-----•-•----•---------- - •-------• -..._•--------- ------------------- ------- -- .. ....... .._•---- --- -- ... 4 ...... .......... .. .............`.__._.____..-_._._._....._ ..... �.fJ .�� Final Inspects :_ ....... Date ....��.7......'3..._ ._ ..._ -••-- � •. SAN JOAQUIN LOCAL HEALTH DISTRICT ' E_ H.13 24 1_'69 Rev_ 5M 7172 3 x�