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FOR OFFICE USV.- �°�' APPLICATION FOR SANITATION PERMIT .............. ..................... :........... Permit 140. .._ _....- 6�0 a Komplett in Triplicate) ........,.............................................. .. ................................................. This Permitfi:xpires 1 Year From Date Issued f Date issued............... ssued Application is hereby made to the San Joaquin Local Health District for a permit to constrckGdnd install the work herein described. This application is made in compliance with County Ordinance No. 549 and. existing Rules and Regulations: - f JOB ADDRESS/LOCATION �� -=,_.-_ _. 57r........ .. CENSUS TRACT �._. Owner'sName ------- ............. ....-� �:.. .... . ............. Phone ------------------------------------ IAddress r=' .....I•... ..............:... . .._ ............City, y .............-_----------,_.-------_---- ....... -/ - Contractor's Name �' d -= - ... Licenseil� � /_. *r'•sPltone !- -? Installation will.server Residence XApartm*t House{) Coinmert:ial❑Traller;Court ❑ + Motel Other................:.........::.............. y � • � !Number of living units:____---- Number of bedrooms _..;n,,Garbage Grinder ./��. Lot Size ,r-� ;,�-tom••--••••---=- Water Supply: Public System and name .....:::....... .. . .._Private ,'- 4 Character of soil to a depth of 3 feet. .S(3nd❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Gay Loam ❑ w --_ A ,,,�Hard-P_0 p Adobe Fill Material ............ If yes,type............... .. ......... #Plot plan;showing size bof lot, location of sys#em"In relation to wells, buildings, etc. must he placed on reverse side.) + NEW INSTALLATION: (No septic tank orfseepage pit,permlmd if pubti"c-ever is available within 200 feet,# i PACKAGE TREATMENT [ ] SEPTIC TANK[ $ Size ....:... ,_ .:........... Liquid Depth .............: .•----• ...... -- CapadtY - Type --- M feria! -------------- No. Compartments . -------------------- o Le Distance to nearest: Well _..--------- ........ .'.:.-): Foundation .. .... Prop. Line LEACHING LINE [ J` No. of Lines ---_---_---------r--- Length of,erich line............................ Total Length .... ---------- �. ©' Box '� Type Filter Material `....`..`......Depth Filter Material •---••.............. Y ----- ;' r Distance to nearest; Well ................:..... . Foundation ........................ Property Line .................... SEEPAGE PIT• [ ( De th - Diameter Number ..... Rock Filled Yes ❑ No ` 1`' Water Table Depth -•••••. •---------------------------------Rock Size ..............t . ,. ........... Distance to nearest: Well j .foundation % Prop: Line --------- REPAIR/ADDITION(Prev. Sanitation Permit# - i .._----•--- Date... ........................... -) Septic Tank (Specify Requirements) ----- - ......... .. . ...-._._......_._... Disposal Field (Specify Requirements •---• •- • - f ............ ..:.......... I-----------------------------------------------------.-.-------------- _.__._.______..._........._.... ....-_............_..._... .................................. l (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 aictordante with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Coca! Hetxlth:District. Home owner of licen- sed agents signature certifies the following: . "I certify that in the performance of the work far"which`thi permit Is issued, 1 shalt not employ any person In such manner as to become subject to Workman's Compensation laws of C4tifornta." fSigned ---------••---• ------- Owner I 'BY _ Title .Ilf t r than o 41 wner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY,--- . .._ ---------------------:.. ............DATE._ .. _. .._., ..: _.: . ._: BUILDINGPERMIT ISSUED --•---.-•-••- ........-•..................... ....... ...........•---•-•.....---•-••--_.... ----... --------DATE . • ..._._._....--------.._..... --•--•. ADDITIONAL COMMENTS -----------------------------------..._... -...__.- ---- ..__..... _ _ r • - -- E y` Final Inspection by: :-_• .. _ . . .........................Date _ ...... EH r 3 2It -bf3 I SAN JOAQUIN OCAL HEALTH•DISTRICT 8/74 3M