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FGR OFFICE USE: + _ APPLICATION FOR SANITATION -PERMIT • - ---------- - ------------------- (Complete in Triplicate) Permit No. -�J-_3w-_____- ----------------t.. '_- -_____-__--_____,___ This Permit Expires 1 Year prom Date Issued Date Issued .f�_97__71___-• � - t Apolic ton-ris hereby:made.-t0,the-.San_Jodguin, Local Health District for a permit to construct and install the work Herein descri6 d. this'application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. "JOB Xi%RESSICOCATION i___ . � v_ �.•i ---- --------- E TRACT a'Owner's Name 'o=dX - = .r c`" CENSUS 4- __ :'Address + r _ Phone ------------------ S — �----------I , ------ •--- City '! ------- Zfe ...�` . . .Contractor's Name ,l ��--- ----------------- -----------------------,------.License #/!t`�2-�X_ Phonef_�� 4: ,Installation will serve: �""~ Residen KApartment Housel❑'Commerci%'l•❑Trailer Court` ;[] 3 1 � � i � r Ntotel'❑ Other __ , ss % {4 g -/___-- Number of bedrooms _ _________Garbo eY _ -` � 01 �Number of living units:`_. n _ Grinder, _ Lot Size _ _ n_ ___� .c - __-_-__ . s _ Water Supply: Public System and name ________ ____ __ _-_---_---.0`-_--- ____------_----------Private Charac er of soil to a depth of 3 feet: Sand' Silt 11 Clay E--1Peat El Sandy Loam Clay Loam:❑ Hardpan L] Adobe ❑ Fill Material ----------- If yes, type ----------------------------- (Plot _____-_-,____________ _(Plot PIan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.};'p.. NEW INSTALLATION: (No septic tank or seepage-pit-permittedrif public-sewer is available within 200 feet, PACKAGE TREATMENT { ] SEPTIC TANK' ----�[ -Y --- Size ------- ------ Li'uid'Depth -------------------------- Ca acit ' ' p Y'� Type Material---------------------- No. Compartments ---------- _ Distance to nearest: Well ____________ _ Foundation --------------- Prop. Line ---------- --��-_ LEACHING LINE [ ] No. of Lines --------- -------------- Length of each line---------_----------- ------ Total Length ----------_------- 'D' Box 4�7 __-_---__.!Type'Filter Material ____________________Depth Filter Material _--_______________.-_ --------------------•- % Distance to n;prest, Well "_________________ Foundation Property Line ________________________ SEEPAG PIT [ ] Depth ---------------- Diameter "-------------- Number ----------------_-- -- _____ Rock Filled Yes ❑ No .❑ Water Table Depth ----- ' -------------------------Rock Size --------------------- -------=-- Y 1, Distance to nearest: Welll---------------------------------------Foundation --------------------- Prop. Line ---------------------- REPAIR/ DDITION,(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------- Septic) Tank (Specify Requirements) _________ _____'__ .__ --------------;Disposal Field (S ecify Requirements) ___ __ _ ------ - �' , �„per+ �T -- ---- - - -------- - --- --- �i� ----------------------------- ----------------- --------------------------------------------------------------:--------------------------------------------------------------- ------------ ---------------------------------=---------------------------------------------------------------------------- ------ . (Draw existing and required addition on reverse side) 51`' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin 'y€--i County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Iicen- a sed agents signature certifies the following: ; 16 1 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 ofcCalifornia." g - ------ E --------- Owner Signed _ Title ----------- -- -- ---- ----- - --- ----- -- Y I {If r than owner} - `' t---------------------- FOR DEPAR NIENT•-USE-ONLY APPLICATION ACCEPTED BY _ _-_____ ,�::p ------ DATE - - Y- °�� BUILDING PERMIT ISSUED -- -- ----------------------------------------------------- , ------------------------------------- DATE - ------------ -- ---_ITIONAI_ COMMENTS --------------------- -------- ----------- ---------- Final Insection by: - ------ --------------------- ------ --------- -------------------------------------------------------------------- 4 - - - --- Date r-711- SAN JOAQUIN LOCAs. HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M