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FOR OFFICE USE: APPLICATION FOR SANITATION PERMITGb Permit No. .7.3 ....... (Complete In Triplicate) _ ... ....... ...... ..... ...... . - 31- 7-3 ...T......_._.._.. This Permit Expires i Year From Date Issued Dat. Issued Application is hereby made to the Son Joaquin local Health District for a permit to construct and Install the wait herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulotlimm JOB ADDRESS/LOCATION � �' ��... f}.1-.if.4�`=:�....... .�. .....CENSUS TRACT ....... . -- --• Owner's Name .........l..t.!V.:\, .��...... t��....... r:......................... ...>Ph�ots ...'�................ Address .. . .... .�(�.�'.,ct..............................._ ...........City .. �1 1.a.1�....`.�4.!rse.+-................ e \ ' S3... Contractor's Nome .. .. �,) . tr fZ�s.ff.."� .:JFJ!t�,.-,�.�.�..............License tlta�, . ..5.' Installation will serve: Residence Apartment House Commercial❑TrallerCaurt a Motel ❑Other ............................................ . Number of living units:.. Number of bedrooms .......Garbage Grinder ............ lot Slits �?..�14.•�CXa----•- ----- WaterSupply: Public System and name .................................... .........................................................................Private — Character of soil to a depth of 3 feet: Sond)� Slit❑ Cloy ❑ Peat❑ Sandy Loam ❑ Clay loom ❑ Hardpan❑ Adobe ❑ 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 tside.) NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer Is available within 200 feet,) l?'1 PACY.AGE TREATMENT ( ) SEPTIC TANK j ) Size................................................ liquid Depth ......................... W Capacity . ......... Type .................... Material...................... No. Compartments ..............�.. . Distance to neoresh Well ........... ........................Foundation...................... Prop. line ......... . LEACHING LINE [ J No. of Lines ......... ........... Length of each line .......................... Total Length ................ _._. 'D' Box . Type Filter Material ....................Depth Filter Material .......................................... Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT [ J Depth . Diameter ................ Number ............................ Rode Filled Yes ❑ No C, WaterTable Depth ................................................Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. line ........._... ...._. REPAIR/ADDITION(Prov. Sanitation Permit* ........ ................................... Date .................................. Septic Tank (Specify Requirements) .. . . ... .............................. . ..............................._....................... ............._....... ....... . .... Disposal Field (Specify Requirements) ........9 f-�.....''` .$.......:!.-!..41' .5.... .? ................ .... . ............. .................... . ....................................... ................................. (Draw existing and required addition on reverse side) I hereby certify that I have propared this application and that the work will be done In accordance with San Jeequln County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Herne owner M Ileen- sed agents signature certifies the following: 111 certify that in the performance of the work for which this permit is Issued, I shall not ompley any person in such mennec as to become subject to Workman's Compensalion laws of California." Signed .. ..... ....... .I...................... Owner (� 1 y ... ... (If other than owner) R DEPARTMENT USE ONLY !'` i �<.v .. ....?'�..... . . . ............................. DATE .... ...�.�/.............. ............. APPLICATION ACCEPTED BY _ .....DATE ... ...................... .......... ... BUILDING PERMIT ISSUED .. .. ..... .................... ADDITIONALCOMMENTS .............................................. .... ........................... ........................................ . ... ...... .......................... �� ... . .......... . ... . ................... ....... ....... .., / ... ... . . _ Date Final Inspection by: SAN JOAQUIN LOCAL HEALTH DISTRICT EXHIBIT D 1 of 2 7/72 3 M E. H 13 24 1.-66 F:ev. St•'.