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FOR OFFICE ' USE APPLICATION FOR SANITATION P:ttiiT S Permit No. . ................ u , 5 tCamplete in Triplicate) }x k�s'] '�lIssued x'76 ..:...._...,�^................................•--..__...... ThisPerrrdtExpearFromDaf®issued Date Application is hereby made to the Son Joaquin Local Health District for a permit to;canstruct and Install the work herein described."This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations, JOB ADDRESS/LOKai. ON .._.•• .� .,y . _ . ._/_. . .... :_. / I��,.4 .. ..4f ,.CENSUS TRACT .......................... Owner's Nam ;`:_ `&. _ a /..� •. ....................... ..... i Phone Address _.:. .,t!?�-. ?�L�_ .. ".,GI ... ............... ....... •--._.. iryt e �� - Cohtractor's Nair1" - --- .- ..__. �2��+License # _ f . Installation will serve: Residence artment House fl Commercial❑Troller Court �.. r I" Motel 0 Other----- = `-----•- Number of,liv,[ng units:..__ ..._ Number of bedrooms .__. ____.-_Garbage Grinder __�L ._ Lot Size ._.•______ x ,�:� Water Supply: Public System and name ------•......-----_ Private -------- --- Character of soil to a depth of 3 feet: Sand$ Silt❑ Clay'❑ Peat❑ Sandy Loam Clay Loam .. p ❑ Hard do Ad obe❑ FIII Material ...._....... If yes,type {Plot plan,-ihowing'sizeof lot, location of system in relation to wells, buildings, etc. mast be placed on reverse side.) NEW INSTALLATION: (No septic tank or, seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ } :SEPTIC K ] Size------------- Liquid Depth ----------- ........ R Capacity .- Typ "56o. Compartments ....... LDistance io nearest: Well --- -- ---:._..-•----• - our f 1i ._.__---- Prop. Line ...... L ngth o#each line LEACHING LINE [ No. of:Lines _. ------ at ___- ._.__-_ .. Total Length 'D' Box . _'`.._ Type Filter Ma#erial :lYr .. . Depth Filter Material _.. PropertyLine ........... Distance to nearest: Well _. .. ....7 Found tion ,.., . f SEEPAGE PIT [ ] 'Depth ... Diameter ---------------- Number .......................... Rock Filled Yes ❑ No Water Table Depth ------------------------------- ................Rock Size ........ � -� Distance to nearest: Well ............................ ........Foundation ..... .............. Prop. Line .................. Ih n Permit t# _ ....... - ©ate ........ s:...........) REPAIR/ADDITION Prev. Sanitatio ", .. . Septic Tank (5pecify. Requirements) --_--.-� _ ��.... -- Dispasal Field (specify ,Requirements) ------• --- ------ ------------------------ -•-----------•-•----------------------------- ........................................... (Draw existing and required addJtion.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 Districf. Home owner or liter- sed agents signature certifies'the following: "I certify that in the performance of the work for which this .permit Is issued, 1 shall not emplay any person in such manner as to become subject to Workman's Compensation laws of California." . Signed weer 9 - •-------------- ------ ------------------- O By ---- Title (If other than owner . wFOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED:BY - < e . . . . ----------- •------ ------ DATE .... � ,_..-.... BUILDING PERMIT .ISSUED _-" 1 ----•--- -.DATE . .------ ADDITIONAL.COM'WENT$.................--------•---------- --------•-------------------------------------- . :;.:. - ----- --- ------------ ,, ,. ,i , ----•...........................................--- ................... ----------•------------------- "-----------------------,-:---------------- --------•---------• -------.:___..... Fin ----------- - :. --..•. . .. Inspection bY' _ . . .. e Date _. .. IrHn.13<r 1-6 Re SAN JOAQUIN LOCAL HEALTH DISTRICT $/7h .314 ~ a;