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FOR-GFFld USE. APPLICATION FOR SANITATION PERMIT ..........................................•-------•-- - N €t o. 7J ` G'S3 lComplete in Triplicate) Perm --...... This Permit Expires 1 Year From Oat*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 compliafIce with County Ordirjpnce No. 549 and existing Mules and Regulations: JOB A,DDRf55J.LOC/t ......-•-- ..... ............... .......................CENSUS TRACT ...............I.......... Owner's Name R _ T�._._ � . .` t9 ••. _r �.... ...... _ Phone A6`9(°74?... Address i.__.---_-_._L '_ _ - a r•City V+ Contractor's Name'�_ ..K?.................. -----License 7191.--• Phone . T Installation will servo: -` 'Residence( Apartment Housefl Commercial oTraller Court ❑ Motel ❑Other + f Number of livingunits....._ Number of bedrooms !_Garbage Grinder r _. .. Lot Size:` :�..7 ��' Water Supply. Public System and name ---....----•............................................._......_ ...... -� ...........Pr€vate ❑ Character of soil to a depth of 3 feet; Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam Clay Loam Hardpan❑ Adobe 0 Fill Material ............ If yes,type...... (Plot plan, showing size of lot, location of system in relation tfa walls;bulldings, etc. must be placed on reverse side.) NEW INSTAL�LATIOI :_(No septic tank or seepage pit permitted If public sewer is avallable within 200 feet,) f r PACKAGE TREATWENT ( ] SEPTIC TANK Size--••.+ _ ............................ Liquid Depth ..- lf 5 .......:....... I Capacity Type artme / . -••--- Distance to nearest Well 4 -� Foundation ----•/�_- -•...... Prop. Line ....13 ..*......... ----•---g ...........•--- ------ LEACHINGLINE `fi(J No. of Lines -----�........_._ Length of each line........ ......... Total Length ---OT_..... J •D' Bax ....✓Type Filter Material .....Depth Filter Material-YT................................... Distance to nearest. Well ...---------------_ ... Foundation -----rQ., ........ Property tine � C { � .��................ SEEPAGE PIT { Depth .-/p---------- Diameter -1C. .... Number ... .... Rock Filled Yes No ❑ Water Table Depth -------------_ ..............hock Size . . r?yr � Distance to nearest: Well ...Foundation ...I4. ... Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit 4IG _...._..._....---•----------------------4-- Date ---•--••----••---•-----........_ .) SepticTank (Specify Requirements) .................................................................................-----•----•-...._..........._............_•.......•---•---- Disposal Field (Specify Requirements) ----------•-•------------------•---••--•----••---••-----------•----•---•-•-•-•---- ----------•---................................ ._.. r ----------------------11— -----.-. •---------------............................................................................................ (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application crud that 'fhe ' 4 rk will ire done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of fire 3'an'Joaquin'Local Hoal&District. Home owner or licen- 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 Compensation laws of California." } Signed - ----- - Owner By ........�--- --- _ ---------------------- --------------- _ Title .....--- - ` jl] (if of than owner) FO EPARTMENT USE ONLY APPLICATION ACCEPTED BY -- •------- --•- ..... DATE ......cg .2�.�. BUILDING PERMIT ISSUED _.. --DATE __.......... .....................:. ..__... ADDITIONAL COMMENTS .............,nu'.!y_.._....... --- C d = --•----------•-•-•------------ - ------ -I--• --------------••----.._.............................•.... ..... ----......... .. .......................... ................ �. ._.. Final Inspection by. ----------------------- • - -•-•-• -•--�..._._............ -- d -. .-•-_-•------•---- ---------_----- --•- • ---..Date .. --- �_ ._�5......_............ EH 13 2h 1-6 v• SAN ! AQUIN LOCAL HEALTH DISTRICT �7)i � [ 1 i* L