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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ------------------ This -73-��Q G y _------------ ------ This Permit Expires 1 Year 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. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION - - -- - .-----=f�-/ z ---------- -------------------------ow -------CENSUS TRACT 'f �------- Owner's Name ----17.1,4Ae7�7_ —+ ---------- -------------------- --------------Phone ----------------------------- g ---� ��------ -�--------- cit Address -----------.e'- �r1 - Y ------------------------------------------------------------ --- - f Contractor's Name ------- ------------------------------------------------ --------License # _---_------------------ Phone --------------------- ------- i�V Installation will serve: esidence ❑ Apartment House❑ Commercial;?Trailer Court 10 Motel ❑ Other -------------------------------------------- ms's Number of living units_____________ Number of bedrooms ------------Garbage Grinder ___________ Lot Size -______________._______._ -------------- Water Supply: Public System and name ---------------------------------•-----------------------------------------------------------------------------Private J ] Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam '❑ Clay Loam-.91 Hardpan�H Adobe-M 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 available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TAN ) ] Size___ t _` _ _______ Liquid Depth ___�____-._____---__- Capacity le-Z.04-------- Type _ Material--�Y`-r-------- No. Compartments --X�---------------- a Distance to nearest: Well ___Sfr------------ __ _ _ _ ____Foundation ___—�_ _ __` ___ ______ Prop. Line 7____________ - LEACHING LINE �'J No. of Lines -----I____----------------- Length of each line-------------s______________ Total Length ------------- 'D' 1. 4 k: 'D' Box __j'a'r---- Type Filter Material 41-If_'_______Depth Filter Material _-J ?-----------.__-__-___---,_--_-_- ; Distance to nearest: Well _ - -- ______________ Foundation :6_-_____._______ Property Line . ,__ - r� Rock Filled Yes No" SEEPAGE PIT �[, Water Table Depth -,/X ____ � -_ ___ Rock Size __!I_ r________________ ❑ 1 Depth I z Number 1 p - 'r! Distance to nearest: Well __ �a�________________________Foundation __I �--_-___ Prop. Line -s '...___......_. } REPAIR/ADDITION(Prev. Sanitation Permit# -----------------'-------------------------- Date ---------------------------------- Septic ____5________________________-__Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------------------------------------< Disposal Field (Specify Requirements) ___________________-_ ' ------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- (Draw existing and required addition on reverse side) 4 = 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 Son Joaquin Local Health 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --- - --------------- - ----------------------------------- Owner BYl - -- -- -- --- ------------------------------ Title (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY> ------------------------------------------------------------------- DATE 0.- ------------ E BUILDING .PERMIT ISSUED ------------------------------------------------------------------------------------------------------ --DATE -----------.-------------------------- : ADDITIONALCOMMENTS ------------------------------------------------------------------------ ----------------- -------------------------------------------------------------------- -=------=------------------------------------ ------ ------- --- ------- ------------------------------------------------------------------------------------- -- Final Ins ection b Date. + _"_ _ P Y --_----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M