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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �f ........... Permit No. .71`"...O (Complete in Triplicate) ............................................ ThiiftirnitExplres,IIYear;From Date 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'.,Jhi-s}application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC _ .. . ...__.__ �f� / ---------•..........................................CENSUS TRACT ..........._.... ......... Owner's Name .. .. . .................. _Phone Address .......... .............................................•-_. City Contractor's Name .., � �-- "'-- �W-l8rf'-----------------•-----.......License # ._......., Phone ......... Installation will serve: Residence f'Apartment House-0 Commercial❑Trailer Court Motel ❑Other ......... ---------------------------- ` Number of living units--../...... Number of bedrooms .X.....Garbage Grinder — Lot Size ................... Water Supply: Public System and name 4 e4..-----•..............................Private ❑ Character of soil to a depth of 3 feet. Sand❑_ Silt❑ Clay_❑ Peat(DSandy Loam {] Clay Loam ❑ ' Hardpan ❑ �AdobeA Fill Material ....... If yes, type ............................ (Plot plan, 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 is.dvailable within 200 feet,) k PACKAGE TREATMENT SEPTIC TANK Size-__............................................. Li [ J ] ` quid Depth ..........................� Capacity ..I................. Type .................... Material.--..---------- No. Compartments ..................... � Distance to nearest: Well .....:..............Foundation .........._...._.__... Prop. Line ...................... {' LEACHING LINE [I] No. of Lines ........................ Length of each line ............ Total Length .............._..... ....... 'D' Box j . Type Filter Material ...Depth Filter MaterialNk Distance to,nearest- Well ........................ Foundation ......... .............. Property Line ........................ • 5 EPAGE PIT [ ) Depth .................... Diameter ............. .� Number ......... _................ Rock Filled Yes ❑ No ❑ Water Table Depth ----- ------=-----------_-----•- ............Rock Size ----------•..................... Distance to nearest: Well ................ -------- ....Foundation ......._.._..------- Prop. Line .............. REPAIR/ADDITION(Prev. Sanitation Permit# .................................:.......... Date ..................................I Septic Tank (Specify Requirements) .....____ y 6 Disposal Field (Specify Requirements) .,0-41d-____-/_-----__-_ __ __. ._. _ _ -• `��•--,- ,�;.�'/ ' ' _ lZ----- ----------------------------------------------- ---- -------- --- --- {Draw existing and required addition an 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 District. Home owner or licen. sed agents signature certifies the following: "1 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 _..� ----•-- ....---- - � y title .44 140n. r (If of than owner) s Z. DEPART E T USE ONLY APPLICATION ACCEPTED BY.::.. . ........ ....... 6 DATE .................. BUILDING' PERMIT 1 D . . . . ,._..• ........ .. �............ ..._ DATE . AD Ti NAL CONI N � �i ri. . ...+�rte: a-f •4' --- f ' ..fig E s=ue r+ ,. ... .-•--�•-..---....... fw.a 4iYf _ _�.. ._::: a ray .....Date :. �. - Final inspection y � _ N AQUIN LOCAL HEALTH DISTRICT F- 14 13 241.'AA Qo., AA '�1 7i_79 1 u