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FOR OFFICE USE: t APPLICATION FOR SANITATION PERMIT -------------- -' Permit No. _72,-4-71 6__ (Complete in Triplicate) ____________________________'___ This Permit Expires 1 Year From Date Issued -i Date Issued Application is hereby made to the Sari Joaquin Local Health District for a permit, to construct and install the work herein described. This application.ii made in compliance with County Ordinance No.--549 and existing Rules and Regulations: JOB ADDRESS/LOCATI�ON ---- _ ----- CENSUS TRACT - ZAW/� � G4Cr � � f Owner's Name /�Dg.- / ��--------- r _. Phone =»l Address - l ------------f� -y-----�---------------- City Contractor's Name -------- -- ----• .__-_------------------- Phone ------------- /- ��-�----------�---P------------------------�------------License❑.# ........._.. Installation will serve: Residence Apartment H�ous`e,� Commercial: Trailer Court ❑ !_7C-0 � -• •--- Motel Other ___ _ _ _ + t, � Q Number of living units_____________ Number of bedrooms _rX------Garbage Grinder __---_ Lot Size ____ ---------------------� s Water Supply: Public System and name --------��✓✓- _____� -_-___-_________- ___________________________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 ---------------------------- (Pl'ot 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 seepage pit permitted if public sewer is available within 200 feet,) 4 JJ PACKAGE TREATMENT X SEPTIC TANK'[ ] Size__`2'-__x x_ ------------ Liquid Depth ---15—XZ- _______- v .F Capacity -�--------- iqype -------------------- -_____- _ _ Material_ ___________ _ ____- No. Compartments ____ ..... \' Distance ;to-nearest: Well ____________ ��CJ----------±----------Foundc --��--------- Prop. Lin;Ag� LEACHING LINK XNo. of Lines -______�__________ Length of teach line___P__'_�.___ Total Length ... ...................... D' 'Box _.___ Type Filter Material _��._ ---Depfh Filter Materiai __Z._'___a�__-/11% ..: ... Distance to-nearest: Well A®o____________ Foundation _ - Property Lin -------------------- SEEPAGE ___________ __ _ SEEPAGE PI Depth ___ ______________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -----------•-------------•--•--- _ Distance to nearest: Well ________________________________________Foundation _________ Prop. Line ___-._________--_. --- REPAIR/ADDITION,(Prev. Sanitation Permit# -------------------------------------------- Date -------------------..------------- Septic -----------Se tic Tank (Specify Requirements) -`"`�-- — __ 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: "I certify that in the performance of the work for which this permit is issued, Ishal�F employ any person in such manner as to become subject to Workman's Compensation laws of California.': Signed ---- -= yh- ��t/ ------..Owner BY -------------------- ------ --------------------------------------------------------------- Title"---- ---- ------ -- -- --------------------- ----------- (If other than owner) i -- -� R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY = ------------------------------ ------------------------------------------------. DATE ---- as ------ I3UILDING PERMIT ISSUED --------------------------------------�- DATE --------------------____-- --- -------------------------------------------------- ADDITIONAL COMMENTS ------- -------`----------------------------------------------------------------------------- ------ ------ ----- ------------------ ---------------------------------------------------------------- --- ------------- ------------------ r FinalInspection by: ........ - -----------------------------------•---------------------------------------Date ----------l7--=/ l ----------- SAN/JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M