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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Z ............... .0 .. ....................._ Permit No. .... .... -------- (Complete in Triplicate) 4.2 I- ( 74 Permit Expires 1 Your From Date Issued Date Issued . ."3-.'4 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/LOCATIONC-1�� -....44 " � < ia.��. ........ .. .. .. CENSUS TRACT ...... ...... ......... Owner's Name �� ........ .... . .. . ... . Phone .. ......... Address J`J O 1p. �%rte e .�L� .... . '. .. ... City .. �... .... .. .. ....... Contractor's Name _.. .tirt-«'�. . ... ....r.-.. . . � .. .. ...........�'t�:.`......Ucense tY Phone .............................. Installation will serve: Residence dApartment Houseo Commercial❑Traller Court ❑ Motel ❑Other ......... Number of living units:..-._.{.. Number of bedrooms .. ...Garbage Grinder .. ......... Lot Size .... X7. .N/G Jam...-:....... Water Supply: Public System and name ............ ........................................_.. --- .............................................Private Q-f_ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Cloy Loam ❑ Hardpan ❑ Adobe Fill Mnterial ............ 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: iNo septic tank or seepa pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK{y ff�� Sizey X ;71 ............ Liquid Depth .,.//............... Capacity � r1C Type L�iLe -. Materioi..,,.A&z-_- .,. No. Compartments =2-r.//...��.........4 Distance to nearest: Well .......... s� .............Foundation ----- ... Prop. Line ....�j r......... LEACHING LINE [� No. of Lines . __3 _ Length of each line.......fC ------- Total length 'D' Box ..._f.... Type Filter Material -----.5 ....Depth Filter Material ...../ ............................... Distance to nearest: Well .......;1.'/?..... Foundation Property Line ..... 7/ �......... SEEPAGE PIT [� Depth .. .`� Diameter .....3.?9. ... Number ....... ............... Rock Filled Yes [J �No i❑. Water Table Depth ------------- 'G. . ..... ...............Rock Size ...�. .�1� .. .. Distance to nearest: Well --------- 1 ...._.....Foundation ---1'/"'""' Prop. Line .... REPAIR/ADDITION(Prev. Sanitation Permit# ............. .............................. Date ...............................---) Septic Tank (Specify Requirements) ------------ ............ p Di osal Field (Specify Requirements) --- -.�- �<frd�i�t. ..- ~� �� .... / - - . . .......... • -- -. - ..... ............. ......._. � �L.L/. .J :c - C <.`-..-_1� :: :.......: :...-. -...1 C._ .. �� 1 (Dr x1sting and required addition on reve side) 1 hereby certify that i have prepared this application and that the work will a done In accordance wills 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: "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 . .- �;14C .. . . _.......... Title 7/.25� . (If other than owner) ffM DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .__ _._ ............. DATE/ BUILDING PERMIT ISSUED .._ .. _ . ._.. ..... .. ... .. _. -.......... ......DATE . ADDITIONAL COMMENTS ._.._... - ... . ...................-----------_--------- ... - __....__..._.... __.._.- .......------------- ---- ...... __ _..._.-_..... __..._.._........ ..................__..... ------ ..... ........__..................... . ....._. .............. -------_.....I..... ..-...... _ ........... ..... - .......... .. - ........ - ................ _.._......................-...._.... ................... ..._............_.. _... Final Inspection by: .. _ .. .. - ' " ....... . .. ... . ...... .. .. . . . ..._...- ..._.-.-Date j:.. U. _? - .._.. - - ...... _max EH 13 24 1-68 Rev. 5M N 9OAQUIN LOCAL HEALTH DISTRICT 87)1 3M