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FOR OFFICE 115E: APPLICATION FOR SANITATION PERMIT F__ --. . . . . �� : .._ .. ._. (Complete in Triplicate) Permit No. ...............---.... ��.7 p' .. ......................... ...-_-....--... This Permit Ex ores 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 an a ' Qg Rules and Regulations: 02-Z Alt JOB ADDRESS/LOCATION /t -_ '-.-<--K.!_. - `- f/ ................CENSUS IRACT ...................:-._.__ Owner's Name ...,-.. - C . -:----.....-- :...Phone . - . - -------•------------------ �a -7ToR7. ..-------•--------.... .. Address -------- ------------ City � Contractor's Name .. D_tiA. 15�2l21�ff_ a � G. License # ............. ...... Phone - �° r�� Installation will serve: ResidencegApartment House❑ Commercial ❑Trailer Court ❑ i Motel ❑Other .................................. o � Number of livingunits-.. . -___. _ Number of bedrooms l 7 � -' ................. � ______Garbage Grinder . ._ ._..- tot Size ........ ....... 1 t [Water Supply: Public System and name - - -- ------------ ..................--..............----- --••------------- ............................Private, s , Character of soil to a depth of 3"feet.- Sand[] Silt.[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ...... ..... If yes, type .......................... . (Plot plan, showing size of lot, location of system in.rel'ation to wells, buildings, etc: must be placed on reverse side.) FI� NEW INSTALLATION: (No septic tank.or seepage pit permitted if public sewer is available within 200 feet, PACKAGE TREATMENT [ ] SEPTIC TANK 7 � Size-............... __...... Liquid Depth _..... Capacity : Type _-._....- ----__--. Material-------- ---- ---- No. Compartments .--------• _. _ - Distance to nearest: Well ,. ... _.... . _ . ......... Foundation.. ... ................ Prop. Line __-_.---.._..-_--- LEACHING LINE [ ) No. of Lines - Length of each `line,. - Total Length ....._.-._........ .__••__-. 'D' Box ._._.. Type Filter Material ..______-___.-__.__.Depth Filter Material .............. . Distance-to nearest: W._ell.-_......__--------------_.F_oundat-ion_ -------------------- SEEPAGE PIT [ ] Depth Diameter ---------------- Number - ______________ Rock Filled Yes ❑ No C] Water Table Depth ------ ---------------------- _-Rock Size ------------------ Distance ____._ _.; ___Distance to nearest: Well -----------------------:--Foundation -------._. ----- Prop. Line .--_------ ........... REPAIR/ADDITION(Prev. Sanitation Permit 1# ........ Date __________________________________) ' Septic Tank (Specify Requirements) ... '''� >tl-.�. q ------ - ---•-- ............ . ........---------------------------------------- Disposal ..... .. ....---------------..._ Disposal Field (Specify Rments) ._. -- _--- t _� � 3" ZS per -- k_. (Draw exisfiing and required addition et verse side) I 5' 1 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 San Joaquin Local Health District. Homeowner or.licen- sed agents signature certifies the following: "I certify that in th performance of the work for which this permit is issued, l shall not employ any person In such manner onto bei me sub' t to WorkmZI—C o ensatlon laws of California." Signed"- -� L ... r 3y . � � ....... Title ... - - .- .._-....-.............._..-. (If other than owner) FOR DEPARTMENT USI: ONLY APPLICATION ACCEPTED BY . c DATE - . BUILDING PERMIT ISSUED . ._. . DATE . -. _. ADDITIONAL COMMENTS ........... ..... - ---------- 4 •----------- ............. . ....................=.......- y . :... -........ ............ =-_. - ---_------- ------- --.. .._. --i Final Inspection by: '- ---- ------------- --------------------------------Date i SAN. .IOAQUIN FtiOCA-L HEALTH DISTRICT:".v e u 13 24, •ta n_.- eii 1 177 1 u