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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .................. ................................ . �! �14.. 7 (Complete in Triplicate) Permit Na. . .--••..................... ......... .........-..........--........... -.._................-.... 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ....... -....--.l.a ._....--.....CENSUS TRACT ........................... Owner's Nome ' . ....... ....Phone Address ,..-._..p_�'../.L.7�......�.'�.. .f,�---1•r •�.�/-•---• -- -------... City . �_�.�............ . ................_................... Contractor's Name ............ ...•• ....................... ........... - Licens"e # 5.��., .. Phone � E Installation will serve: Residence 5(Apartment House-E] Commercial OTrailer Court C Motel O Other G ".:. Number of living units:......._._._ Number of bedrooms.............Garbage Grinder .._._.... ... Lot Size Water Supply. Public System and name -..................................... -•....................................... ---- _----------------Private ' ' Character of soil-to a depth of 3 feet: `I-Sand O—.Silt EJ _ Clay-E]""' PearO==Sandy-Loam O Clay Loam,R Hardpan C) Adobe O Fill Material ........:... If yes, type .................-......... (Plot pian, 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 seepage pit permitted if public sewer is available within 200 feet,) C PACKAGE TREATMENT ( SEPTIC TANK T J I Size-------------------......................... •-- Liquid Depth ................ Capacity .. .. ... ......•_ Type - -.:. ,..:_._...._ Material..-_-.--- -----._-•-.. o. Compartments ....................... �... Distance to nearest: Well ........ ...........................Foundation ....._. ............. Prop. Line ....... fLEACHING LINE [ ] Nil. of Lines . .- ----- Le gth of each line .....................'... Total Length ....................... 4 4 m---"D'- Box_..' .. Type Filter Mat r;al^....•' ........,.Depth Filter Ma eria! ..................•, , Distance to nearest:_Well-..-.... .............. Foundation ----- ---- Property Line .. SEEPAGE PIT [ ] Depth .. .. _... ._....-._ Diameter Nurrtbe -= _._,_ Rock Filled ;Yes-[D No i Water Table Depth -.--------------- - ----:-----------------------Rock Size ....._._ y'. - II •-•----- ---------Foundation ._....:..- Prop. Line ':....`.:......_.......Distance to nearest: Well ........... ....... REPAIR/ADDITION(Prev. Sanitation Permit sly ---------------- .......__...__.._._ Date ...•---------------- -------------1 ' f Septic Tank (Spe6fy Requirements] .... � � f ... .. i t �= `�. .................... DispoDi sal'-Field--(Specify Requirements)--:-::..._..-- ----------- ------------------------------------- .................. ......... .... . '..-tel __...,�.._ -._-. -..--...--- _ _. — _ r iisef:' ......_. r-- - —... i f'4 ..ti 4 r (Draw existing and required addition an reverse side) _ I I hereby certify that I have prepared this application and that the work will lie-done,in accordance�with-San_Joaquin County Ordinances, State Laws, and Roles and Regulations of the San Joaquin Local Health District:-Home. owner or li'e`n-`~ sed agents signature certifies the Following: 1. + "I certify that in the performance of the work For which this permit is issued, I :hall not employ any person in such manner as to become subject to Workman's Compensation laws,of'tciAfornio.',' 6 Signed .... __.......__. ..........`..., Owe 3' By _... .. . -------- --------- ----- ................ --------- itie . ... ....... (If other than owner[ t j -- ---- -__- W-- ____ FOR DEPARTMENT" •S ONLY . APPLICATION ACCEPTED BY ....- j.ir1-0-- f----- _ :, . :...-.'... DATE �I_�./5:. . .......... BUILDING PERMIT ISSUED ................._. .. .. '.------.---- ------ . ..... ,.. ........t....'s._,.DATE _ . .. ADDITIONAL COMMENTS-..._ r- -, -- - ---------- ------- ------ _ ------ ----- ---------- ---- ---------- ..----- ..... ------ .. ------ --------- --.-.. _ .. ------------------ Final Inspection b - p y: ....... ------- ... ..-----. ---•• -------•---..Date ...:. .....................�� _... --- S AN --SAN JOAQUIN LOCAL HEALTH DISTRICT _ i . i F. H_ 13 24 1.-AR pa�.Lsn 7/77 3