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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --- (Complete In Triplicate) Permit No. -------------- _ This Permit Expires I Year From Date Issued Date Issued ?—U 3- 274--,0 f 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: JOB ADDRESS/LOCATIPWXZ� � �G '. . (+------- - ---------- S r TRACT ........................ Owner's Name Address .__... ------<--�_s ...l.:� n� /� _ ............... tT`�!1_! ... ......:.._City,. o .. Contractor's Name ...............• - / -:._..... License # . Phone t� �' .. . Installation will serve: Residence ❑Apartment House 13 Commercial`❑Trailer Court Motel ❑Other .. 70-67 -- Number of living units,...._.... Number of bedrooms ..:Garbage Grinder Lot Size , Water Supply: Public System,and name s �Y ................:...........,............. - Character of s�oif to a depth of 3 feet�Sciiid' ........ � ...............P •.-.. rlvata .. a 'Silt❑ Clay -❑=Peat❑°'�Sandy Loam± K Clay Loa �__,�,__^ _. F A#ft � Hardpan 0 Adobe ❑ Fill Material ._..... .... If yes, type (Plot plan, sho% 'g e�of lot�I cation of system In relation to wells, buildings, etc, must be placed on reverse slde,l NI:VIf;INSTAILATION: `�� t f"y u'1•�, I Q (No�septicank or seepage pit permitted If public sewer is available within 200 feet,} " PACKAGE TREATMENT [ ] {t'SEPTIC TANK "' ize.... .... ...... .. .. Liquid Depth .! .............. VN Capacity � . Type � - -•_-.... Material...-CO No. �Compartments� . P�.�', .� Distance to nearest: We .._ d- __Foundation /. .... Prop. Line . ...... ..................... LEACHING LIKEN. t . ... Length of each line.._7� No, of Lines .... Total Length ../:. ............... x 'D' Bax ............. Type Filter Material . .. .. .. ......Depth Filter Material ._.±.•,- �O IDistance to nearest; Well �1 r ' ---�•__-•_ .... Foundation ......T....__...... Property Line d T ... ... SEEPAGEPIT Depth ..... - `-- . * � Diameter ._ ......... Number .__.... Rock Filled Yes No . - .tWaterTablDepth ......................................... .....•-- Rock Size ._ ..- ....r.?� Disace to,nearest:-Well I / Q. -Foundation / ....Pr- �� 9r . .REPAIR/ADDITION(Prey.Sanitation Per # Date -.-'• _ ,, fir.. ••--- ............................. "CSeptic jank (Specify Requirements)' .........i:...:__..__.... :.. ............ . . r ....... ..,Qa ......... . �Dispo a!-Field"_S c fi Re uir l p Y q ements)........................................................................................... F. '• . .............................•_-....._..___•_r._............-----•-- ..... .. .......:..s......__.-_..........-......._._...... .' (Draw existing and required addition on reverse side) _I hereby certify.that. 1,have prepared.this,applicatlon.and,that the work will be done In accordance with San Joaquin County Ordinances, State laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the Following:,. , "! certify that in the performance-ef,thezwoik�for which this permit Is issued, 1 shall not employ any person in such manner as to become subject to Wa�kman'SlCompensallon laws of California." # Signed ......................... Owner V�_ y By _ ............ ............ 1 (If other a owner) . FPR DVARTMENT USE ONLY s APPLICATION ACCEPTED BY .:........... - � DATE .....h'� .... 7> : . ... . BUILDING PERMIT ISSUED ................... - .._____....._.....•_•.__- ...DATE ..................................... ADDITIONAL COMMENTS ' :...:........................... ...................... ....................................................... ...._._......_._.......------•--........._.....__........................ 9_. ..................................... Final inspec't'ion by: [Y G .... ................................ Date ...:.1...:.1.... — �s;�............ SAN JOAQUIN LOCAL HEALTH DISTRICT u 13 241-•,�n n___. - —-- l