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"FOR OFFICEUSE: APPLICATION FOR SANITATION I� PERMIT , ...._....,_....:¢..................... ..... (Complete in Triplicate) Permit Na. ..................... ............................................ Date Issued .../r`.'-�.�•7� This Permit Expires 1 Year From 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: a p , . .....V.7cENSU5 TRACT = = JOB ADDRESS/LOCATION l. Ll �''. -� 55.1........-..- . . ......�........ . .. Phone ��Lo h one .......................... Owner's Name ._._..� ... �_ - ------- .....---.....---r .... ........................ Address ......... ...................---•---::,---••------••• City Contractor's Name .......Ar._ ".. ..-'.$A..... Phone f Installation will serve: - -- --Residence ®Apartment House-0 Commercial ❑Trailer Court ❑' s Motel ❑Other -------------------------------------------- 14- Number of living units:..... Number of bedrooms .__ 3..Garbage Grinder ... .... Lot Size ...._. ...:•.-" `.... ................ Water Seipply: Public System and name .......... Private ®' �_ ....,_�..,�r..•�„ "-- - P ' to Character`-of,sail.to,'-o depth-of 3 feet: `Sand ❑ Silt❑ Clay ❑ Peat Sandy loam C3 Cloy Loam ❑ Hardpan Adobe F1 Fill Material ............ if yes, type .--_----- --------------••--- (Plotplan,,showing size of 'lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION:.. (No septic tank or seepage pit permitted if public sewer..1s available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ] Size.__�il...X n..1�.��_. •....:_....`._�.. liquid Depth ...�.----•--•- ...--_..r G Capacity l ....... Types C` Material----------------- `No. Compartments _�.....-----:...s � e Distance to nearest: Well _ i ....................Foundation 4e .............. Prop. Line .-.G?.__..._........tS� LEACHING ' r r [ No.•of Lines .. ... Length of each line.---5 ............... Total Length -- �' �'•---••............. LINE ] .:r,,�__--_:_. ._ .: D' Box Type filter Material / ? Depth Filter Materiol ...1_l'.�---•-��-•••••---• . -- --.r... / 4 f" 'L 444" E Distance to nearest- Well �af�.1.'d...............�N�beron.... ...._._...... Rock Filled inYes � ---No-[l I� E SEEPAGE PIT [ ) _-,Depth `I� t '.�L__. Diameter F �� blDepth �` ..... :Rock Size ......----••. . ............WaterTa --�----- D�istance to nearest: Well - 1ondation -----......... ..... Prop. Line ........ . ........ •---••••....-•-. ...-Fu . ' .. Dat .......................... REPAIR/ADDITION Prev. Sanitation Permit�# • . Septic Tank {Specify Requirements) ......°_,.._-__.-_ ... ........... ............. ............ ......._._.,....._..._.. ........ Disposal Field (Specify Requirements) ..---• = ----------- ------------------------------------------ ------------- -------------••------------------------ L,__......,. �,. . I --------------------------------- _ ____ ____ ........................... t t # {� . ••--•- k Draw existingand required addition on reverse ---------------------............:_.._...____..-.__.._._._._ ... ----------------- _ 4 i side} this application alion and that the work will ber hereby certify that 1 have prepared pp done in etc, with San Joaquin I County Ordinances, Slate Laws, and Rules and Regulations of 'the San J6aquin local Health District. Horne owner or lieen- 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 subject to Workman's Camensation laws of California." j Y �- G�` �Ce .. Owner rf�.__........ _...... Signed -- r w Title ..3 .. .. _..••............................ ' (If other than owner) `Y' FO EPARTMENT! USE ONLY, Fee{ 1 ....~•...:...:......DATE .�--� �.��............. APPLICATION ACCEPTED BY .. .-- - . - -- - - ---._ .................................... ...................... ' 7 BUILb NG PERMIT ISSUED - ............................DATE ........................................... - ; , ADDITIONAL COMMENTS ..................... .................................................................................... ....... . ----•- ---------------- --------------------------------------------------------- Final Inspection by: ...: - SAN JOAQUIN LOCAL HEALTH DISTRICT + _ . - 7/723M