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MIX QFFICE USE- 01 * .. v APPLICATION FOR SANITATION PERMIT cam... 3. ... .. . _. Permit No. ..7.6....3�..�. . rJ' .�.........--- 4Campiete in Triplicate) .-•.................................•... This Permit Expires ] Year from Date issued Dote Issued .ter_ .:3" _� ... 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 compliances with County Ordinance No. 549 and existing Rules and Regulptionst JOB ADDRE55/LOCAT#ON . ........ -. f .....��0..._. .................... . —A- fx . ... CENSUS TRACT .......................... Owner's Name ... ........... . �1.. .-• ... ._ _ :;..... ...... Ph4 Jne Address •-------- -- ---- -------- -(.._..:. __. City --• -•. Contractor's Name 0,License #�,Fz' / Phone _ Installation will serve: Residence X, Apartment House❑ Commercial❑Trailer Court ® Motel ❑Other ----------------- f Number of living units:.... Number of be rooms _- Garbage Grinder Lot Size ............. .. . ................ Water supply: Public System and name ..--- .. _ - _ _ '---...._� �"� Private----------•• -• ❑ Character of soil too depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe Fill Mcrter€al ....-------- 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Si e_ ,�+ Q ... �{ Liquid Depth ._. .............. Capacity/A0re6 ryl/,Type -Material.. o. Compartments .-- .............. Distance to nearest. Well -7?¢ -.-----Foundation __/-----------... Prop. Line ---J - LEACHING LINE No. of Lines--`../-_-__-I....... Length of each line...... _ .... Total Length /�42 'D' Box .._ Type Filter Material _.::Depth Filter Material .. F r Distance to nearest: 'Well f r ff/_ ..e Foundation ��._.............. Property Line .. �...�....--- SEEPAGE PIT Depth --s --- € " meter rte . f Number ..___ ................_._.._._._ Rock Filled Yes No iQ Water Table Depth __!.__-- ...�--`•---------------------Rock Size . Distance to nearest: Well ... =_.C ,!`, :'•••-_Foundation -. _r_.._. Prop. Line _.. �. ._.... REPAIR /ADD iTtON(Prey. Sanitation Permit# ..._..._....._..�,., p, ' �_-............... Date ...........`fit.._,..-•-----•---1�...,,._.. �.. Septic: Tank (Specify Requirements) -----•.............__.....------........, ... .---.._.....-- Disposal Field (Specify Requirements) ................ .... 3 -------------------------------------• -----'--•-• •- F------------- ------------- -•--.. r S, ------------._....----•-,•�-----...._..-_ A ----------------------------------------------------------- ---- - _. (Draw existing and requiredAadditian on-reverse-side) .. ... _ ..... t 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. Home owner or licen- sed agents signature certifies the following: "I certify that in the pe#ormance of the work for which this perWt Is issued, I•shall not ernp'14aany person In such manner as to become subject to Workman's Compensation taws of California.',:_ Signed Owner ---... BY C � � Title , = {_ -- .:: -__: (i other than owner} �;: ;°, R DEPARTMENT USE ONLY a� APPLICATION ACCEPTED BY ---- -------------•--------------------I -_.----------------- ----.. DATE --- --- �` -- ------------ BLIILDIN43 PERMIT ISSUED ------- ---------- T f ----------------------•--.------•- ....DATE ..----------••--•- ....................... AADWTIQNAL COM NT��..... , - --- ------------------ - _.._._.. . ------- - ---------- -------------- ............. ...............^ _---------.............................................. .......... ---------- -- ..... _. . Final inspection by: ----- ....... ........•-._.._....------•-••-------.._....-•---....---•-----_.._._...........�---•--C---- _ " .... EH 13 21 1-68 �N JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M i