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FOR'OFFICE USE. APPLICATION FOR SANITATIONPERMIT ........... •..............I...---......_.....- Permit No. .. -9�a.:. p8 (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Dote Issued .fib:q�Y. .............. ................................•• P Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application-i�ynade in compliance with County Ordinance No. 549 and existing Rules and Regulations: ' t - Jk JOB ADDRESS/LOCATION ....:..`__._._.�__.. %...:.............•.. ......... ...............CENSUS TRACT ..........:...:........... Owner's Name .......................................,........................I............Phone ............. Address ........ ............. City ........._....._:__... •- ---•....... .................. Contractor's Name �% �i 10�G 5'p.�/ (� license #ga �� Phone ... ...............•.... . og Installation will serve: Residence ❑Apartment House f:] Commercial f5Trailer Court ❑ Motel []Other s-s0 ,�?. Number of living units.-.-. ...... Number of bedrooms ............Garbage Grinder ------------ Lot Size ................ ......................... Water Supply: Public System and name :..................,__ . - - ------•.....------••--•---•-------------•.._.---•---------•--------------._.........._Private ❑ Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loamc� Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ............ If yes, type ............------_------- (Plot ..... •-----__(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 INSTALL � EATMENT [ ) SEPTIC TANK i ] Size.. �a�.: �Q -............... Liquid Depth .......................... `l Capacity --- --------------- Type .................... Material-----------------_-- No. Compartments ...................... i Distance to nearest: Well .l- ----- .................Foundation _Iv ........... Prop. Line _lrf�.r--••-• LEACHING LINE ( ] No. of Lines -------- ----------- Length of each line._/l_e l___.._....-_- Total Length ................... � D'-,i-Boz ---- pe,FilterTMaterial� --___..•-__...._..- pth-Filter,�M-dteriaf Distance to nearest: Well4... ---...... Foundation ........................ Property Line ........:.......... :.--- SEEPAGE PIT [ ) Depth Diameter ..... .....:... Rock Filled Yes ❑ No [� 1 ••-----------=---- -- - .. Number Water Table Depth ..Rock Size Distance to nearest: Well ........................................Foundation ...._....._... ..... Prop. Line -----------........... REPAIR/ADDITION(Prev. Sanitation Permit ............. Date Septic Tank (Specify Requirements) ...........................• -----•---..._....---- ---•--•---•--•--.............._..------...................... - Disposal Field ASpecify Requirements) .............................. ......................................................................-.--.................... .:......... - -- ---------- - (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 licen- sed agents signature certifies the following: . - "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Com ensation laws of California." ;. Signed ._�� t� JJ.S OAj ... 4N.gC.T�.. Gip- 5?i � -�.---- Owner By .--.1 =-••-..... - Title ....J �' ss !u (if other than_.owne :---_-• i FOR. DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .,....... ....................... _..............----•-• .. DATE ....t`?..:a4 :`. �-/............. BUILDING PERMIT ISSUED :................... ADDITIONAL COMMENTS _..------•----•...:............................ ••• ..._._.......: ' ------------------------------------- -------- -=---- ........................------------............................................................................ . --------------------------- --- - • • . ............................................................ .............................................. Final Inspection by: ... --• •--••• ...................................... .............Date 1�- .�'..... ........_.._. _SAN,JOAQUIN,;LOCAL HEALTH DISTRICT 7172 3 M .E. H.1.3 241-`68 Rev. 5M.' ... r=�, �'- ', '. _