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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT . . Permit No. .� :/07 .. 1Camplete in Triplicate) y � Date Issued _.-.P?k`D/ This Permit Expires 1 Year.From Date Issued t . � Imo` Application is hereby made to the San Joaal He quin alth istrict fora per it to construct and install the work herein described. This application is made in compliance with Countyprdin e=Na. 44 and existing Rules and Regulations: JOB ADDRESS/LOCATIOIrJ/ r'!ll.,G .. .... . . '.�`...-- .. ........ .....CENSUS TRACT Owner's Name ...... .... .......... ............ _ -- r ......................................... ......Phone.Y797: ..0.4� ......... Address .._...... /. 0.... .. + .... { / .f ,'�. City --- i , -------- -- Contractor's Name e ._ ....... -_.License # 3-'f 3.-__ Phone ' `sa -f-Installation will serve. Residence Apartment House-E] Commercial ❑Trailer Court ❑ Motel ❑Other ------- ................................. Number of living units:..... . Number of bedrooms ___-.Garbage Grinder . . ........ Lot Size ..__ �.._1� -P ............. Water 5 pu ply:aPvblic System and`iname .....----••---------------------•--.------ ------ . •-------------------._...-----•--•----------------•-----Private i Character of sail to a depth of r3 feet "Sond❑ Silt[:3Clay E] Peat E3Sandy Loam [DClay Loam El 7--_.Hardpan Adobe) Fill Material .._.. if yes,type ............... (Piot plan, showing size of {otlacation ofsystem)mrelation toeils� buildings, etc. must be placed on rev�erer.side.) NEW INSTALLATION: (No septic tank•:or seepage p1t permitted if public sewe is available within 200 feet,) E PACKAGE TREATMENT ] SEPTIC TANK S}ze`__•:y `_..... "...._. .... Liquid Depth ...:�` !��- ----•� Capacity ,f�f ? Type _h _-.- Materlol..� No.A'Compartments -----?�........ Distance to nearest: Well �� ' _._.._.___.._Foundation ....14 Prop. Line LEACHING LINE No_ of Lines �-' .. Length of each line ......S.57'....... ...... Total Length ........... N D' Box .._._C.�Type Filter Material _ .._.Depth Filter Material ..._ _....�.. -.'�.....:................ Q Distance to nearest: Well ........ Foundation �.p._;"f`..._. Property Line ... .............. `r Ro k Filled Yes No ❑ SEEPAGE PIT Depth meter _. Number .._--.. ..........._ Water Table Depth ...___._- -`'��- _�3_..�_a. a) Rock Size .. ��- ..y0y--./!__.- - iometer `r' r Distance to nearest: Well _... -._______.___.-_Foundation ._.. Prop. Line ..5.......`........ REPAIR/ADDITION(Prev. Sanitation Permit# ............................_...._._...__. Date _._.-_._--._..___.._-.________..__) Septic Tank{Specify Requirements) .... . ................. -- -------------------- -...-- .. ---...... Disposal Field (Specify Requirements) --- - -----_-------_.......... --------- - • . . --•---................................... . .................... ............. (Dra'w existing and required addition on reverse side) I heicby�ct rtify that I have prepared this application and that the work will be done in accordance with Son Joaquin County�C)rdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Ilcen. sed agentstsignature certifies the following: "I lcerfifylthat 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 F_ Owner _---- - - ------------ ... ----•.............. ...... Title .... ......................_..... x (if othe t an owner) FOR DEPARTMENT USE ONLY ARPLICATIN ACCEPTED BY --- ..._...0.. .._. .... �._.. _.' .-- -_- ------.�... ---_. DATE BU,ILQ NG PERMIT ISSUED __. ..- . ._.._. DATE r ADDITIONAL COMMENTS ..//.. . af7 ... .-• - ......................... ................................ ................ ................ ----._......_-- ... . ---'.. ----•------. .........---•-..... ..:. ..Final Inspe tion by: . --------- -' - •-.... --•------•----------- ------- -- -_ .......----------....-- ._.._.. .- -•---....Date ..`L_ ... 0 _. .---..._........ SAN JOAQUIN LOCAL .HEALTH DISTRICT t f. -