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FOR OFFICE USE: ;: APPLICATION FOR SANITATION PERMIT ........................--------_------••--•- (Complete In Triplicate) Permit No. .................... _........... ............................... ds. ......................................... This Permit Expires 1 Year From Date Issued Date Issuedd.'.�..r..P...r • Application is hereby made to the San Joaquin Local Health District for a permit to ,construct and install the work herein described. This applications made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ......7 - .,./ ?�J2�L�9�lt .. ..S7a.�. T�? ......CENSUS TRACT ......:................... Owner's Name ... V/L1.... .z000w/ z-� �6 3323 ........................................................................Phone .................... Address .............. ----------City ..... .T0.4'.CTo tJ_.._............_... ....... Contractor's Name ,1A�:Llcense #' Phone .4` ... .. Installation will serve: Residence ErApartment House Commercial OTrailer Court � Motel0 Other.----•...................................... Number of living units:.... Number of bedrooms _-J-----Garbage Grinder .../........ Lot Size ............................................ Water Supply: Public System and name ...............................----------.........._.........--•---......-•-----•-•- ...................Private { Character of soil to a depth of 3 feet:. Sand Li Silt 0 Clay 0-Peat 0 Sandy ,Loam ❑ Clay Loam 0 rHardpan 0 Adobe .Fill Moterial ..._.._..... if yes,type (Plot plan, showing size of lot, location of system in rel"tion to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit perm t�e�di L , y ilc sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TAMC.i ] ize................ ..•----- -•-- !��-t�.hLiquid Depth .......................... 60 { Pe NoCompartments o ..........- Capacityi4yt - _ [ Od Distance to nearest: Well ..Foundation Prop. Line T .... Total Length 1.7x1............. LEACHING LINE [ j No. of L-Ines�....................... Length of each line_._.g--_�J_...._...... .. ---__--.._... 'D' Box .- -85 Type Filter Material T45!%........Depth Filter`Material ._9.................. -1........... } ` Distance to nearest: Well ...: a._.._.__��- Foundation _.._.� _....._._... Property Line .....��............... SEEPAGE PIT [ J Depth .ate- ----------- Diameter 3......_. Number ..__..._aZ...............`� Rock, Yes No i Water Table Depth .--------77-5. •-------------------Rock Size ....r*.....Z.'?...--•- � Distance to nearest: Well ........................Foundation ... ...... Prop. Line ..................... REPAIR/ADDITION(Prev. Sanitation Permit..54t ..............:-Date ._........:..a............... r Septic Tank (Specify Requirements) --------------•--...__....-•---•---•-----------................------------.........---._-_....--.......---........_.._..._.._............... Disposal Field (Specify Requirements) ----- ............................................................----------------------•-••--•-•-------------_--------- ----- ----- "` (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be clone Ili vivicordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heal&.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 Compensation laws of California." Signed -------------•------------ -------------.------------•--.........•............................... Owner By ---------------- --------------- ----------- --------------------------•----- -----------•. ------- Title ---•-- ----- (If other than owner) .- R �IJIEPARTMIENT USE ONLY APPLICATION ACCEPTED BY - - -- ---------------------- ------------------------ DATE /allay '...._...- BUILDINGPERMIT ISSUED __------------------------------ ---•-------•----- ............ • ..........................DATE ....-----...---•-------------------------- ADDITIONAL COMMENTS _ X--- --�''--� -•---- -- --- ------- ---------------•-•-- ....-----------•-- ...................... . 9 --------------- - ----- .. .._..__---_-------------------------------------- �;----------- Dot Final Inspection by: Date`�4.. ..Z.d�7S. ..---_..._. 13 2 -68 v. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7,h 3M