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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT icomplete.in Triplicate) Permit Na. ....7._..- ........................ This Pernriit Expires 2 Year From Date Issued Date Issued --f- e.-7� 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 Na. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION. ... -�'/..G.rc�....... I _.. -........ ......CENSUS TRACT � 'j ... Owner's .Name ...•G ._�. .. ............................Phone . Address .........C121T/P e . , ............... city.City a.-.../ ' .��. .. ..... ............. •. .. .....Contractor's Name Phone ..... .................:..... Installation will serve: Residence ErApartment House C3 Commercial{,Trailer Court ] Motel ]Other............................:................ Number of living un'its:.._.../.--- Number of bedrooms ._--f.r3 Garbg9 ............ to Size-/12_e_2_ � e Grinder Water Supply: Public System and name __ Character of soil to a de .............................................. ..........................................Private Q'' depth of 3 feet: Sand b !to Clay ] Peat A Sandy Loam 0 .Clay Loam p - Hardpan Adobe Q fill Material .. if yea type. ............. ............ ....... p " {plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) NEW INSTALLATION: (No septic tank or seepage pit ,permitted if bl€c sewer is available within 200 feet,) o � PACKAGE TREATMENT ( ] SEPTIC TANK �L i ..., .. -. '. .......... Liquid Depth ....f ............... Capacity Io`l PType -S: - Material.. � �,_ Flo. Compartme rEtti .w Distance. to nearest: Well - ----��-'.� -Fovndation ••. J Prop. Line . .. . .......V1 LEACHING LINE ( No. of Lines ...-_..._ ��------------- length ol` each line...__.!��:.... Total Length .... 'Q' Box .._ f._:.. Type Filter Material _.....Depth ...... .. ...,�. epth Filter Material T..:�. Distance to nearest: Well J . ---••��' . Foundation ..l.a.. r-' - ..... Property Line .......a.��. SEEPAGE PIT ( Depth -� ft .. . .. Aiarneter .��..�.---, umber . � .._ hock Filled d Yea �No Q ...----•-........ Water Fable Depth .........../..4. ...�. .Bock Size !•1 ....,,� ,.�� ....... , Dist ....-•---= t)L'e__ Distance to nearest= Well . .............Foundation �!ci. Prop. line .....Sl. f REPAIR/ADDITIQN lPrev. Sanitation Permit ` ...... . Pate € Septic Tank (Specify Requirements).._,,:.....:_ Disposal Field (Specify Req.uirementsl ------------------------------------------------------------ .... - -----.......I.............: .......................................... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work milli be done In accordance with San Joaquin-•a County Ordinances, State Laws, and Rues and Regulations of the San Joaquin Local Health;District. Home owner or )icon- } sed agents signature certifies the fallowing: "I certify that in the performance of the work for which this pemrylt is Isoved+ I shall not employ any person in such manner as to become subject to Workman' Compensation laws of California," Signed -._... •- -------. . r-----------------•-- Owner !. BY -- ----- . . Title ....................... .. t zee ........................... Of other than owner) _.. i FOR-DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- DATE .........._. �.� ...:........: ...... .............................................. ------ •-_..._ BUILDING PERMIT ISSUED -------------------ADDITIONAL , Final Iris ection by-- .----- i EH 13 2!� 1-�6t3 1Zev, -----------.__._.. _ {:�.�' ..............Date ...... :. .. . i SAM JOAQUIN LOCAL HEALTH DISTRICT 8/7h 31"1 i