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FOR O I=ICE USE: ' APPLICATION FOR SANITATION PERMIT ................ ...�.........._ _.�..�,�.�. (Complete in Triplicate) Permit No. .. .....- -- ..............................#..,?i.-d......... -� `" -� - This Permit Expires t Year From bate Issued Date issued LFti _ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein I described. This application is made In compliance with County Ordinance No. 544 and existing Rules and Regulations: i JOB ADDRESS/LOC//#TIa��._.. / 9..�1`r...._......---- ---._._........_..............CENSUS TRACT .:........................ ` .. .. PhoneOwner's Name Address .................2 ......... 1/44; ..1... �f City ... Contractor's Name ....License # �JPhone Tw� Installation will serve; Residence ❑Apartment House O.Commercial ❑Trailer Court ❑ Motel ❑Other .� :-,� G %�-- Number of living units:.....(..... Number of bedrooms ..........-.Garbage Grinder `_.:_.......Lot Size ........10/ �.--..-, i Water Supply: Public System and name-.J1-.',--........... --------------------------------..................... .....................PrivoteX .ea. Character of soil to a depth of 3 feet: Sand •. Silt❑ Clay ❑ , ' Peayt❑ Sandy'Loom 0 Clay Loam ❑ 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.) w NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) -� liquid Depth .......................... PACKAGE TREATMENT [ ] SEPTIC TANK S' e_______________ _�....._...-..:-------- -- Capacity1? -� • Type :---- Material....-••-.._-- --- No. Compartments Distance to nearest: Well —_. .Q..t- ' Foundation ....��,fi...... Prop. Line .:< _. . .`--.-. engt � l� r V I LEACHING LINE No. of Lines ..------I.---_------ Lh of each line.._.../0110..../0110....'.... Total Length ...�.......... .......... r. 'D' Box ............ Type Filter Material ---Depth Niter Material _._,�q................................... i Distance to nearest: Well ...5_�._ ....... Foundation ...... D..�t---•-•• Property Line .5' ..:'�_........ ' SEEPAGE PIT -4- - Depth .. .._ Diameter__:-�_.(o:..:_Number ::.:..�.:...._:.``.//.._-._._. Rock Filled Yes No Q Water Table Depth ............................-_-•:-....•........Rock Size .�1��.�e�•��•� ' Distance to nearest: Well ......_l0d_. `...............Foundation -./Q ..... r p Line - r.•.......... - - - _ Po � REPAIR/ADDITION(Prev. Sanitation Permit 5f` _...,:.. ............_------------•-•_-- Date ......__...... ................... Septic Tank (Specify Requirements) --------- .....................:....-----.....----•-----....------.......-------•................I.......--........_....._•-- ; 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�done. in 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 following: t: "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 wo Workmnan'i;Cotnpensation laws-of-California." Signed --.�.,T....._ -- . "_ -------- ---1— r ------ ------ •... Owner By .......I.... ...... . ...'---..._. ---....................'•.,_/t -Title 1 j ............................................: b (if owner) FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY ..__......`.. �•-- / f '-.: DATE .: 1.- � 2 S BUILDING PERMIT ISSUED � � ""....BUILDING = ..................DATE ADDITIONAL COMMENTS ..../�..:..•-._.. ..... . 7�.7. .............. ...-----•-- ........ ......................... . .......---.......... Final Inspectiori by: --- •--- . .... . .. .... ........................... /ry.J�}. 3....... / _>' A LHEALTH DISTRICT I 13 24 .= ,,ETH. 1-'68 Rev. 5M 7172 3-.K