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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7�_ 3 7 o , Permit No. ..................... t (Complete in Triplicate) - - Date Issued . .....:.:.:............. ............:............:..... F This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construet and Install the work herein described. This application is mode in compliant with County Ordinance No. 549 and existing Rules and Regulations: Cf: 2/+�7� ��,.....CENSUS TRACT ... JOB ADDRfSS�LOCATiON ...yrs i.. .!—.—.............................. ...._ . Owner's Name V �- -s ,L r'T.._._ of ...................... �............ 3.0 .....Phone . . Address ................................. 1?2.41J..............-----....I......_..----..... City .... ....... ..... .. ........................................ Contractor's Name ...�� •fyt ,j �5v. /_..... '----.License # Installation will serve: ResidenceApartment House CI Commercial OTroller Court 0 Mote ❑Other .................•-•-----...•----. ......... Number of living units ..... Number of bedrooms Garbage Grinder Lot Size ...... -••••-•••• Water Supply: Public System and name .Private ..._ Character of soil to o°depth of 3 feet: Sand E] Silt 0 Clay ❑ Peat❑ Sandy Loom{3 Clay Loam Hardpan❑ Adobe❑ Fill Material ............ If yes,type ............... ............ (Plot plan, showing size of 'lot, location of system In relation to wells, buildings, etc. must be placed on reverse NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) N PACKAGE TREATMENT .[ SEPTIC TANK I I Size................................................ Liquid Depth ....... ............ a Capacity j ype ...... Material.................. No. Compartments ... .................. I ....Foundation Prop. Line . Distance.to nearest: Well •--•.....•--- i �( ' LEACHING LINE No. of Lines --------.1.. . Length of each line.----./.fie%-........ Total Length ---.. •.................- 'D' (lox Type Filter MaterialDepth Filter Malarial ...... ................... ....•....:............� t ` .......;5% Property tine Distance to nearest: Well �� Foundation ..._ OfSEEPAGE PIT [ I Depth .-• -----...-•---. Diameter ----••----...__. Number .......................:.... Rock Filled Yee [] No Water Table Depth -•--•---•- ---•••......-----••..................Rock Size ................................ Distance to nearest: Well .foundation .. Prop. Line E 'REPAIR/AQDiTION(Frau. Sanitation Permit qp -=-•--••-•------•----=-•-- Date ................................... (A ............:.....•-_-••) r Septic Tank fSpecify Re uirements) ....................................................•..........I...........I.............. i Disposal Field (Specify Requirements) •.... ...... ...•------............----....... ..----......----...... k --- ------------------------------------ ...................................................... ...............................................................................I...... .......-••......................................... I (Draw existing and required addition on reverse side) I hereby certify that 1 have prepbred this application and that the work will be done In accordance with San Joaquln County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,Disirlct. Horns owner or licett. sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in such manner as to becorne subject to Workm n's Com ,sation laws of California." Signed ...... � r - ------ ; Owner $ ------ T tle -------------- Y . i (If other than owner) FOR D PARTMENT USE ONLY APPLICATION ACCEPTED BY ------------ -, ------------------------------- DATE ....-.t1..2 -� a BUILDINGPERMIT ISSUED ---- ------------------------------------------------------------- -•----DATE ......_-.--------------------------- - ADDITIONALCOMMENTS --•---------------•------------------••- ------------............................ ......................-------------;--------------—------------- ..---------- ---------------------•- ---------..-..-------------------------.-........... ------ -- i ---- -----------•-----------1:........... Final Inspection by.............------------------------ -s c _..._ ..--- .......Date ......1....-. �------•---• ------ IIT 13 24 1-69 Rev. 5M y SAN tOAQU1N LOCAL HEALTH DISTRICT 8/7h 3M i