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` _FQ.R OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------- - ---------------- - ------- --------- --- { Permit No. -7-�-=--S-�-I ;1 (Complete in Triplicate) ------------ --------------------------- 'ff 5 y �v �. Date Issued -------_--- : This Permit Expires 1i Year From Date Issued 4 Application is hereby made to the San Joaquin Local Health bistrict for a permit to construct and install the work herein described. This application is made in compliance with County,Orclinarid-&No:"'549 and existing Rules and Regulations: 1. ' (`� ®� -- CENSUS TRACT ----------------------•_--- JOB ADDRESS/LOC .�---!_-_ -- - -}---- 5�+ �---- ------ f"`! /(�C/r- -- ------------ Phone �2.��'�_. _ Owners Name -_.___ °,._ __ `` _-- ----- Address City __- - � -- ----------------------------- Contractor's Name -------- -------i •---- -- r1// 7 - --- -- -----� d�" - ------------License #i��_��-�------ Phone Zt¢U_`�_°�_..-_/__---- 4 Installation will serve: Residence Apartment House❑ Commercial []Trailer Court iO ---- � Motel ❑Other -------------------------------------------- Number - - ------------------ ---------------- -- -„.s a� Number of livingaunits:° _/- Number of bedrooms __-3-----Garbage Grinder _.-__--____ Lot Size _S------------------------- - ---------- I Water Supply: Public System and name ----------------------------------------------------------------- ---------•-------------•----------•---------Private Character of soil to a depth of 3 feet: _S_and,'E_ ] Silt0 Clay❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ • Hardpan E] Adobe ,Pill Mflterial ---- If yes,type ----------.----------------- (Plot plan, showing size of lot, location of system in relation YY wells, buildings, etc.'.must be placed on reverse side.) ` I NEW INSTALLATION: {No septi t nk or seepage pit permitted if-public sewer is availabEe within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[,.], # eSize--- ---------------------------------------- -- Liquid Depth -------------------------- t - ---------------------Type -------------------- Matetial---------------------- No. Compartments i F ,'---- - 'Foundation --------- --------._ Pro Line ---i-------- -------- -- \ Distance to nearest:. 1111e1i ^_ __ .__ - _ _ p• -_ _ _. ._,_ __ r .. ,.�� ._.. LEACHING LINE { ] No. of Lines ------------------------ Length ofYeach'line-_- __________---____"Tofal 'Length ,._________._______-.-.._--- 'D' Box ------------ Type Filter'Material __-__?- _-_----Depth Filter Material --------------------- 1 Distance to nearest: Well .__ _________________�:Foundation -------- -------- Property Line _____-__._.-..-......... SEEPAGE PIT [ ] Depth ____________________ _Diameter ---------------- Number _-___,__--____._---_,_-_�•. Rock Filled Yes ❑ NO .❑ : t 1 E�r . � �, t Water Table Depth ------------------ i`-`--:------ ------- Rock Sizei;-----------`-------.._--------- -`t'`e} . - Prop. Line Distance to nearest: Well -______________________________________Foundat.ion _- - REPAIR/ADDITION(Prev. Sanitation Permit#--------------------------------------------- Date -----_-------------------------) I t k "ri y Septic Tank (Specify Requirements) -------- --------------- - ------ - ---- ------ ----- ' , _...,.- .,. .. n Disposal Field (Specify Requirements]` = ' ---------------------------------------- -i------- 1 �� �.S-- -- ------------------------------- ------- 1 9 ,. n in _ _ { -__________________ ____ ________________________?_._____--.---__-__-________------_-______-___i______ } ` (Draw existin and.,�e wired addition on reverse side) I hereby certify that I have prepared this application and that the work will be doe accordance with 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 followin _ 4 "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 - ° = ------------------------------ Title ' r (if of er th n owner] •� IV �. FOR .DEPARTMENT USE ONLY .tom / APPLICATIONACCEPTED BY ---__ -` - ----------------------------------------------------------------------------------. DATE _- .---- -- - --------- BUILDING PERMIT ISSUED -- ------- - --------DATE ---- ------------------------------------------ ADDITIONAL -------------------------------- - - 4 ADDITIONAL COMMENTS .- _ � .T - jj / ------------------ fof S f 7 _- �C ,es - C,lr �-_� -------------------- % ------ -- — -----------=------------------------------ --------------------------------------------------------------------------------------'------------------- I - -- - ------------ ------------------------------------------------- - - - ' ,7 Final Inspection by- ------- .='s- _ ------------------- - ------------------ Date 6 `� __..SAN,'JOAQU.I.N-LOCAL_HEALTH_QISTRICT,�,,, 4 N E. H. 9 1 'W-Rev.,_W.