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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT t....... --"..............•.....I._................_ Permit No. ....�y_97....... (Complete in.Triplicate) _.. �F Q- �y 7y '- --- --------- This Permit Expires 1 Year From Date Issued 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 Ordinanc No. 549 and existing Rules and Regulations: l JOB ADDRESS/LOCA . .--- .... .. ... _...CENSUS TRACT ....:.........:........... ' Owner's Name . - -•• •••. .. .... ..............•.... . ...------.._...........................x Y hone.._, ... ........-• Address .... .. -----. .......... ,f•�/.�_.._ ...... .. .. ��_.. - -• - • -••------:.. ,City .... ...... .. ... •�. rn'i t f Contractor's Name _..._. _ ..... ..:. ..................... ...i . •----------- --..:License # _f�t}��cc��._ Phone ........,..................... Installation will serve: Residence [Apartment House Commercial ❑Trailer Court Motel ❑Other.._........................••--••----•---•--- Number of living units:....... Number of bedrooms t5.......Garbage Grinder.......:..... Lot Size .....................!Pip................... Water Supply: Public System and name ...................•--•......................................-- ------•------•---------- ...........P11 0te Character of soil to a depth of 3 feet: Sand _Silt❑- Clay ❑ Peat❑ Sandy Loam Clay Loam Q Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type it (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 see ge pit permitted if ublic sewer is available within 200 feet,) ii PACKAGE TREATMENT [ ] SEPTIC TANK Size. ......... Liquid Depth ...7..................... Capacity��J_• Type i Material__ _..___. % Compartments ;I _.�...:.... Distance to near it. Well ._._.._.... .--................Foundation ------------------ Prop. Line -- ..... ......... LEACHING LINE [�� No. of Lines ....____.Z__...:..... Length of each'line --------.--------- Total length ........ 'D' Box !....... Type Filter Material ....-5. .....:Depth Filter MaterialI7`'.-:--------'..___.._• I Distance to nearest: Well ._....1� . ........ Foundation .. r1................ Property Line � 'rkll Depth ....8-14..... •Bra_t t)VZZ2�Z Number .----------..3............... Rock Filled Yes No i❑ • Water Table Depth ..............r!r=...........................Rock Size __.I ....... j Distance to nearest: Well .............. ��... ............Foundation ..ld.-�...... Prop. Line -:5 ............. REPAIR/ADDITION(Prev. Sanitation Permit# ... Date SepticTank (Specify Requirements) ........................................................................................................................:.._................. Disposal Field (Specify Requirements) .................................................. ---------._-----_-------.._.-.-- ................... ................"•-----.......................__..._...---.....---•----------•----....._.......--•-••---•--••----------------------••-------------...-------•----•--•--------•. ................ II (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 Man 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- "I "I certify that in the performance of the work for which this permit is issued, I shall not employ any person In!suth manner as to become subject to Workman's Compensation laws of'Californlb." Signed ------------- ------ -- -----. Owner - y .� (5 ' By .. .------•--.... 1.�?�'�.-,i..... ------ ._------•-------•--- ---._ (If other than owner) FOR DEPARTMENT USE ONLY ;I APPLICATION ACCEPTED BY ..---•-• ............(;"T... DATE .....ld .4 .il .._.......__.... BUILDING PERMIT ISSUED ..........................::.................•-•-......................................................._-DATE .....................A...•--•••............ ADDITIONAL COMMENTS --;•------------ ------------------•-------•-•-- --7-- •- !�..........---•-- 0 * --------------•-----•-••--•---------•-------_..... .._...,... .. ..................... ....._..._...... __......_.........I.........._.. .......... ............................. Final Inspection by: ...................... .e-=••----....-- ...Date ..� � �._. SAN JOAQUIN LOCAL HEALTH DISTRICT ,-P E. H. 13 241-'68Rev. 5M 7/723'9'