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FOR OFFICE: USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. .7.5./-11.,fC. •-•---•••- ------••-_---••............................... This Permit Expires 1 Year From Date Issued Date Issued .371 :751 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 .. . �r8_;,- .•4 ' CENSUS TRACT .:........................ Owner's Name ........ -------------------------------- -------------------- ........... ...... Phone ► ." _t1�1.� . 4 � Address ............ '-' ..:.......... .� City _ . :... Contractor's Name -- --...... ............. ..- $�_-. -------------..----..License #CVS_Y... 3.... Phone Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑ Other ............................................ Number of living units:..._ __.... Number of bedrooms ..__..------Garbage Grinder ......... Lot Size ............ . .. y '------------ Water Supply: Public System and name ...........__................ .. _. r�r -?�.................Private ❑ Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ 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.) NEW INSTALLATION: (No slepticrtank-or seepage-•pit:permitted.if.publ.ic ewer.is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK j Size----------------------------- ....-..... Liquid Depth ............ Capacity ....... Type -------- ---•-••---- Material. . ......... ...... No. Compartments ..................... Distance to nearest: Well ............. N t -------Foundation ......._------,....... Prop. Line -------•---...._..... LEACHING LINE [ J No, of Lines Length of each lineToI -.---•. ... ..... ...... tal tt?.engfh, __�..------._......_._..-...� D' Bax Type Filter 11�1`ateria ------------Depth Filter Material ----------- - - ' , Distance to nearest: Well -.-------_-------.-. Foundation .... Property Line ....................... 1 SEEPAGE PIT [ Depth . . .. ........ Diameter ---------------- Number ____.... .... ............-. Rock Filled Yes ❑ No ' Water Table Depth ....... -_-----------_----•--......Rock Size ............... t-�-�--_ --------------- ---------------------Foundation .......... . .t_.... Prop. Line .....•--•- ..........� REPAIR ADDITIONSanitation Permit# - ......................-_. r" istance to nearest: Well / (Prev.i ---=- --_.... Date -•----------•----...---•....:..-:.) ii , Septic Tank (Specify Requirements) ........ �_1 O 1 : . • Q_ _fa Vir ----.. Disposal Field (Specify Requirements) ---.- `- -.:_.. _4 I ..._--._....---- z.- .. -------- -- _(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!Aealth District. Home owner or liven- r sed agents signature certifies the following- "I certify that in the performance of,,the work for which this permit is issued, l shall not employ any,person in such manner t as to became subject to Workman's Compensation laws of California." Signed ...... ..... ............. .... .... .. -- ......-•---•-•-- ---- Owner ' ` J .�C.•�rtxnw...... .!# .�.:.1........... title . �- � (If of r ha owner} .._..-..__. FOR-DEPARTMENT-USE-ONLY APPLICATION ACCEPTED BY .., ....... DATE ... ... ...1...' .�........ BUILDING PERMIT ISSUED _ ....... . --- ------•--------- ............DATE . .................-................... ADDITIONAL COMMENTS ................. . ............-----------------------•-.- . ....... --•-- . ...... --- . -'I ................... ........ _.................................... •......... .........- _...... . --.. ---- ------ Final Inspection by: ------------------- ............. ------------ Date ....- - ` � SAN JOAQUIN LOCAL HEALTH DISTRICT C�