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FOIL OFFICE vSE: APPLICATION FOR SANITATION PERMIT } Permit No. .....................7� �Z .......�_��n...�.�G�........................................... ... .,. ,...... .�. ' Comp#ata In Triplicate) . �"" ""'�" " Date Issued _,23 .;7A, ..... .. . This Pennit;Expires 1 Year From Date Issued Application Is hereby made to the San Joaquin Local Health District for a permit to constrict and Install the work heroin described. This application is made In compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . T. .�• `{... �. ... ..� ..CENSUS TRACT .......................... Owner's NardeF ....... ...P�,S:�.~ ..�W.v. ....CENSUS phone Address ... . _CQ,.........................City .... �...................(.G r.- ! Contractor's Name ................ -`- .. ...............License $ :_.�. :,t�. i'hone ...G--..km. ....... f Installation will serves Residence Apartment House❑ Commercial❑Trailer Court ❑ i - Motel❑Other .. ..................................... Number of living units:__....... Number of bedrooms ..1�.. ----_Garbage Grinder ............ Lot Size ..... ..- ,: .......... 0 Water Supply: Public System and name ................ .._•-••--..c.........................---..__.,........._......._.-------•-----....--..............___-___.Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 9K day Loam t� Hardpan❑ Adobe❑ Fill Material ........... If yes,type ............... ............ (Plot plan, showing size of let, location`of system in relation to wens, buildings, etc. must be placed an rov�s'se side. NEW INSTALLATION: (No septic,tank or seepage pit.permitted if.publit_sewer.is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ] . ...... _,__x__�.... ........... Liquid Depth ..V5...:.............. =::Z - Capacity. [ Typo . Material--- CompartmentsT. ...... a 1 t r ' Distance to nearest: Well -•--•- ..Foundation ....ZQ.. Prop. Line ........ ..».--- LEACHING LINE No. of Lines ___. .-..�.-.r Length of_____-� line.........TO_:...... Total Length .��Y0 .- .......... . 'D`"Box..-.✓. TypoAlter Material .:. .a.Y�'..L....Depth Filter Material .........../e.."....... .... ...... . , Distance to nearest: Well ...:..�$�.e.---•__ Foundation ......<.0./ �. .. . Property tine .�f. ............ i .. Diameter Number Rock Filled Yes No ❑ SEEPAGE PIT [ I Depth -.-•--•------..... .. ...... ._ ❑ 4 Water Table Depth ................................ ..............Rock Size _...._......�:................. Distance to-nearest:_Well ........................................Foundation .................... Prop. Lina ..........-......... .-- REPAIR/ADDITION(Prov. Sanitation Permitk .........__................................. Date .................................. SepticTank {Specify Requirements! .............................................................................».... ............:........._...............-................ Disposal Field (Specify Requirements) ............................ ......._...__.... ............. �: : ......................................... .. .............................................................. ......•-•----........ ................................-................................ •----------------------------------------------------------.---•----...............................__.....-•---.....----••-•-•--................_................-.................._._.................. (Draw existing and required addition on reverse side) ! hereby certify that I have prepared this application and that the work will be don: In accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of.the San Joaquin Local Health District: Home owner or lieu sed agents'signature certifies the following: "I certify that In the performance of the work,for which this.permit is issued, l shall not:employ any pwson In such manner r as to become subject to Workman's Compensation laws of California." Signed ...............; ...---- -- .... .......- ..................... .:Owner $ {....... .. .......... it e ....._......-- C. ....................................•.---•- y . ... .: If of er t -owner) 1~'t. -- .. Lr FOR_DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.........-- / . .... :..�".. DATE ...... . ........ BUILDING PERMIT ISSUED ........DATE ADDITIONAL COMMENTS ..................... . .................................................................................................•-..............._._......---.._............._....._......._.........-• ----.__.......................... ....................................... ............. ..... ............. ............... -........................................................-..................................................................... ............................... ........ ... final inspection by: ..._._.... :._.-.............. :..Date ...... . EH 13 2!i 1-613 Rev. 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3M