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FOR OFFICE USE: APPL7Permit TION FOR SANITATION PERMIT ----------------------- ---- ----------------I_,�l_?4S------------ Permit No. -' (Completein Triplicate) bate Issued --- ------------------------- ----- -- 3tQ , c7---- Thi / Expires ]Year From date I � ssued 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 OrdinanceNo. 49 and existing Rules and Regulations: JOB ADDRESS/LOCATIO ----�U-- ------ - -- -r - - - CENSUS TRACT -------------------------- Owner's Name ____,_.. - � ----------Phone -- - - - - - -- ------- -- Address I � ----- -- City Contractor's Name ----- � � -------- License # Phone Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ J y Motel ❑ Other .-----_yTgAt tcs------------ Number of living units:..._------------ Number of bedrooms .__________Garbage Grinder ____------_ Lot Size ___.-__- -------------- Water Supply: Public System and name ------------------- -r Private ----------- Character of soil to a depth of 3 feet: Sand'❑ Silt❑- —Clay--El Peat❑ Sandy.Loam ❑ Clay Loom Hardpan ❑ Adobe ❑ Fill Material ---------\? if yes, type ---------------------------`-- _ J (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,) C4 PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size_____________ `-------.------------ Liq uid Depth -------------------------- r�1 Capacity -------- Type -------------------- Material----------------------- No. Compartments -------------------_- Distance to nearest: Well __-_______________________________Foundation ---------------------- Prop. Line ---------------------- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line_____________-------_ Total Length ____--_ -------------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material _-____-_.__.____--- ------------------------ N Distance to nearest: Well ----------------------�, Foundation ------------------------ Property Line _._____________________ SEEPAGE PITyS Depth -----�---------- Diameter --:----�- --- Number ---------------------- ---- Rock Filled Yes ❑ No Water Table Depth _ - ____' ------Rock Size ----------------------__- Distance to nearest: Well ________________________________________Foundation ___________________ Prop. Line __________-___-______- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------- i- --------------- - --- - -- ----------- ---- ------------- --------- -- --- - -------------- Disposal field {Specify Requir encs) -- --- --- ---------- -- -------- --------- --- - ------------ - - ---- - ------ ------------------ '� tj -t�� e� �` a4n1�'y�a `(a-Q� 4 I!b tri �r ori �:1 i C- a7r �� --- y (�mt•dr t,H 6HC7Ccu e r exi tingland required adds ion on rev€�se sid p / I hereby certify that I have pfrepared i s�ahcbtWn a6h&1th9d9the'rwo1k wilplihe'do a in actor ante wi 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:; + ' ,Y ". I • "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 become subject to Workman's Compensation laws of California." Signed -- -- - ----- Owner �? By -------- ------- i�_ _""'-------------------------------------------- Title ------� - --- -- ------------ -------- than owner) •DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- ----- r ---------- ------------------------------------------------------------ DATE = BUILDING PERMIT ISSUED TE ---------- -------------- ADDITIONAL COMMENTS - �---- ------------ - -------------------------- ----- - -- ----------- - - -- -------------------------------- --- -- -------- ------- �{- f ------------- ------ --------nspection Y Date -------------- g-y�, �,.. 4 .o�ofL� �� / SAN JOA IN LOCAL HEALTH DISTRICT 17 ow P-4 E. H. 9 1-'6B Rev. 5M 7