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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT µ.............................................. ....... 73-9oZ/ (Complete in Triplicate) Permit No. ......._._.. _..., �. This Permit Expires t Year From Date Issued Date Issued/. _. V.... 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: a JOB ADDRESS/LOCATION .--•--- - f-3 cryca...... �-.._ .1.t-1_ _._.. < ..... ................:CENSUS TRACT .` .7....:....._._.._ Owner's Name -...................Mo.Mleo.r_---- ............................ .....................................Phone Address .. 0S[.. '�.-S. r.�-•-•- ............. City , `jC.64J. Contractor's Name -t......... -t.i : ',;. I?-R��c --. =--4 �►..--_._---•-. .....License #A,5'� (a---.- Phone ...(/-6( ?7. Installation will serve., Residence [ partment House C❑ Commercial ❑Trailer Court ❑ Motel ❑ Other .........: .....:...---------------------- n Number of living units:....... ._.. Number of bedrooms __.......Garbage Grinder ............ Lot Size . J�!..... "....fir.' Water Supply: Public System and name ..-- ................ -----------------------------..------..-.____..................,.......Private K 'r Character of soil to a depth of 3 feet Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 rY — - HardpanAdobeJ;—Fill (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,) r PACKAGE TREATMENT ( ] SEPTIC TANK[ Size.....Mzcx�>__ . ..... Liquid Depth .._.. .......... s Capacity -/ �4 -TypePr-t,-0.0t.Moteria!_. Y-��No.r Compartments ...............%y �( Distance tol. nearest: Well ...... ...........Foundation .....1 .4`:::_.. Prop. Line y______.. p LEACHING LINE [ ] No. of Lines .. ..c .............. Length of each -line...-..JC_-........_.. Total Length __ ......... 'D' Box .._.r...... Type Filter Material _.....Depth Filter Material _ X.sV.. ............................... 1 �{ f s d� S , Distance to nearest: Well -.-..._.:.v__:__.... Foundation l�....-....-- Property Line ...------ SEEPAGE PIT Depth Diameter _- ..... Number Rock Filled Yes4 No Water Table Depth _..----.... .�_a�•. _.-•------- ----• •-•------Rock Size I � _ + .............. .....4P Prop. Line .._.�s7f............... i REPAIR/ADDITION(Prev. Sanitation(Permit# --------________........................---- Date _--------_-------------- t '� } s Q Septic Tank (Specify Requirements) .. ----------------------------------y------------• --•------------------ -----------------------:...•-------•---------- ...... }� i Disposal Field (Specify Requirements) ----------------------------•--- -----------------------------------------...-_.................----------- --------_-_-__-------- � F _.... - - _:.......................... .. ........... .. . . - - -- - �:.. - - _ .- -- �.� : � - (Draw existing and required addition on reverse side'}' � I 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 licow. sed agents signature certifies the following: t "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner F as to become subject to Workman's Compensation laws of California." Signed ........ . .. -------------- By . c.. . --•--------------•-------•• Title . .... 1f...... t (If other than owner) . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .-..-. r .................... ............. DATE _ •----_-- BUILDING PERMIT ISSUED .... -- Y` ....... ........ .................. -............. DATE .................................... .... .., ADDITIONALCOMMENTS - --------------------•------•----._----._..--......_--- ..............._......._...._...-•-- •.._........_.......------...._..._......... ----•.... .......... ---------------------------................................ -- ----- -------------..._._..--------------- ....... ............... f ................ Final Inspection by: ..- � ---------------------------------------------------------..Date ..�4`.1L7--',�`.�...--I.,......... SAN JOAQUIN LOCAL HEALTH DISTRICT z u 11 24 7172 3 M -