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tFOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ........... ........................................ Permit No. ..�. :. 3. IComplete.in Triplicate) ......................................... This Permit Expires 1 Year From Date issued Date Issued �.cl� . .." . ' Application is hereby mode to the n Joaquin Local Health District for a permit to construct and install the work herein described. This application is mode in compliance with County Ordinance No. 5549 and existing Rules and Regulations: OB AD RE 7A)- , TIO oSS......0 r�1' � FA...�L�,t! ..--- ----XA................CENSUS TRACT - JOB ADDRESS/IOCATION .............:............,.......... ' Owner's Name ..;.........0.40.Q_......n.. 4� .�1...........................................Phone. �r �s Address .._.........� r/Ir... .. h � . ...... . . ity ...........................•----••---.................... .................. Contractor's Name .... . . License tis .� Phone Installation will serve: Residence Q Apartment House 0 Commercial❑Trailer Court 'Cl t -Motel [}Other 40,0491-f`-�/'�! ✓ • �y®� ' Number of living units:...........t Number of bedrooms ............Garbage Grinder OV..Q... Lof Size Private)? ' .... Water Supply: Public System and'name .............................::...:_'.__.".-........:.._.........----.......--•-----••----...-...__.........Pri ate ' . Character of soil to a depth of 3 feet: Sand]] .Silt❑ Clay'Q Peat' Sandy Loam Q—'Clay Lotl'm Q- T sow—• c:__ 0 I Hardpand ' Adobe Fill Material... If yes,type I " ... ..`..z_ _ .y 111 01 ' (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,)., 4 PACKAGE TREATMENT ( ] SEPTIC TANK bff Size/r* Liquid Depth ..e,.. ............_ Capacity--- Type - - Materiaj- o. Comparfm .._..... ...... I ' Distance to nearest: Well L?�Y....................Foundation .. - ........ e ,WACF1TIgUTtE [ ] No. of Lines .. ........_..... Length of each line...�Qpi. !._...-..... Total len ') ' ® IP1.4 pow 'D' Box Nod_ Type Filter Material Depth Filter Material ~ Distance to nearest: Well .... ...... Foundation ........... Property Line .. , ......... ' SEEPAGE PIT [ ] Depth Diameter Number ...................__..... Rock Filled Yes ❑ No ❑ Water Tabie Depth ............... ...---................--------Rock Size .......................... ..... Distance to(nearest: Well ........................................Foundation ............... .. , rop. Line ....:,................ REPAIR/ADDITION(Prev. Sanitation-Permit# _...................,...................... Date ..................................I Septic Tank (Specify Requiremnts)t DisposalField ISpec':fy Requ rements)............._.............,..............:_............................... ....................................................... 1 l - - - ....................................•-7--- ..-s........ - . __...,,-_ ------... .. .. a "' (Draw existing and required addition on;reverse side) I hereby certify that I have prepared this application and that the-work lwlll be done`inaccordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the.San Joaquin Local Health District. Hem* owner or Been- sed agents signature certifies the following: l ° ' "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 sub[ecP Vlo Signed .......... .By`:..:.......................... ... ,.................... J(tle ... lr,JJ c _ ....pfoth FOR DEPARTMENT USE ONLY ' BUILD( ADDITIONAL COMMENTS ..., .lA� .... .. ......... .. ..................�.................. DATE ----f.�.�....�.�.................. APPLICATION ACCEPTED BY (!�. �a..`.. �..4�1� BUILDING PERMIT ISSUED. '............ .........._...............r . . .... t DATE.��.1l......:................................ ................................... ......... ............................................................... -.......................................... .............................................................................. ..... ..... .. ?.:. ._.............. _... ...... .....ate .�.�.....� .. �.�......................._..........----.....`.'....................... .....ate ............:....... .................... .. ... ' SAN JOAQUIN LOCAL HEALTH DISTRICTi9/ e u 13 242_1Ao oma., s:sa 71723 M