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An FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ^ 4 ---� � ................. q Permit No. ...7. ..-.v .S�/ (Complete in Triplicate) ...._._...:1f ' ............. .............. Dote issued � � _ I This Permit Expires-1'Year Fral'm Date issued .......................... 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 - �' ' CENSUS TRACT ` .... ..................:.. .. _ Phone Owners Name �• L 3 �a � , .��'� '_"_.� '_��. Address . ......_i ....... CitY --�----------------- 3yG,3•-•-..._............................ Contractor's Name `¢ """ Ph no e X0.7...-• :_ , .. ._ i- License # ` •----- I � .- Installation will serve: Residence ❑Apartment House❑ Commercial-OT-railer Court 0 Motel M Other ----•........................ ......... t5: � Number of living units ..... Number of bedrooms _ ....GarbageGr.,inder�_:.-:_.._.___,Lot_5ixeg._JOfi -----•:.••-••• private' Water Supply Public System and name ... --- --•-------- -- •-- ............ Y Y �!! �Character of soil to a depth of 3 feet: Sand❑ Silt❑ -Clay ❑ Peat❑ Sand Loam Cla Loam [[ r�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 side.) NEW INSTALLATION: {No septic,tank or seepage pit permitted if public sewer is available within 200 feet,)-- � " �r E PACKAGE TREATMENT [ ] SEPTIC TANK Sixe._/,r + ...... Liquid Dept .....- Capacity fio�P� Type Jl"�-.�' .._ Material.. No. Compartments ............:: r lto nearest Well 1 r �.'` ...Foundation ~Prop.-tine _ ........• o - --....._. .. . v G LEACHING LINE No. of Lines --------I............. length of each line....... Total Length ..1�r.�".... '.:: Distance 'D' Box --- _'Type Filter Material .......Depth Filter Material ...la ................. e --:-•- Distance to nearest: Well ....��sa.. ..•.- foundation Property line SEEPAGE PIT Depth .....rQ."........ Diameter 9��Krc . Number ... --.................... Rock Filled Yes �` 'N0,0 „ Water Ta -----"�'••••-- ble Depth ._...._.....Rock Size ► Distance to nearest: Well -------r0?t"- `...................Foundation ..-�-�r -- Prop. Line _. .-.-•-- REPAIR/ADDITION(Prev. Sanitatiari Permit# ......................_•-- -- Date .........................••----...) I ,.a Septic Tank (Specify Requirements) ...................... ......................................................... - ......... Disposal Field (Specify Requirements) -------- ---- •------ ------ ---------.--------------------------•----..----------------._...-•-------17,71l ... -•�_ . il. _ = - ------------ --------- -------------••----------------•-•-- •.................. .�...a rt.. .. _- ----------------_--------that I have prepared this application and that thetiwo k will rbesd e) 1 hereby certifp p one in accordance witln�San liaquin r County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen- 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 suchmanner as to become subject to Work n's Compensation laws of California," Signed X OwnerBy .._.-...._.. ..... ......... ... Title .� :._.................. (I. other than owner[ 4 t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY;I......... . .... --••••• DATE ..._.....�.` _ • BUILDING PERMIT ISSUED ...'...... .............. ......................................-DATE ........... __ ....................... ADDITIONAL COMMENTS i .................•...........------.......------........--- ---------------- G _....--•-•----•--------------•••••••.-•.........--_- :......----------.........---- Final Ins action b ..Cern_.... .Date .. SAN JOAQUIN LOCAL' HEALTH DISTRICT I 'L 7/723 m r W 13 24 1_-.ca o— rAA