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FOR GFFiCE USE: `;"PLICATION FOR SANITATION PERtvtr- (Complete in Triplicate) Permit No. ----------- ------- --------•----- / ---------------------------------------------. Date Issued .____. This Permit Expires 1 Year From Date Issued Application is hereby made to the Sian 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 ------ C T G-�--=---- �t -----__J. r�C_�.��f v.CENSUS TRACT ---------------- Owner's '- {------- Owner's No a :7� �_' I ` Phone --------------- Address - - -----------•----•------- Address -'44.r.� ��1»-� ----- i /- 2«. .,« , %J / city Name ��. �,%._ ,; � _ L t �` .-.._-___License # - _ Phone . Installation will serve: Residence ❑Apartment House❑ Com cial!Trailer Court :❑ Motel ❑OtherE_ - Number of living units:---.-------- Number of bedrooms ..___-----.Garbage Grinder --------- Lot Size ---------._.----- ------------------ ....... Water Supply. Public System and name ----------------- ------------------ •--------Private n 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.) L, NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) t ' PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size-------------------------- ...... --------- Liquid Depth ----------- -------------- 1 1 Capacity --- ---------------- Type ---------------- --- Material-------------- No. Compartments --------------------•- Q Distance to nearest: Well -- ------- .....................Foundation ---------------------- Prop. Line ___--..-._-.-.-____. LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---..------___ .-... Total Length .___._.____-___---____-_. 'D' Box ------------ Type Filter Material -------------- -----Depth Filter Material .-_-___._-------_-.__-------------------- Distance to nearest: Well .----------------------- Foundation ------ --------- Property Line ____---..---__-_._..-. SEEPAGE PIT [ ) Depth -------------------- Diameter ---------------- Number ----------- ---------------- Rock Filled Yes ❑ No C Water Table Depth -----------------------------------------------Rock Size ----------------------- ------- Distance to nearest: Well ----------------------------------------Foundation ----------.--------- Prop. Line _.___------_.------ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----- _------------------------- Date -___-..-_-..._......_.----._-.-_-.) } SepticTank (Specify Requirements) ------------------------ ------------------------------------------------------------------------------------------------------------------ Disposal Field (Specify Requirements) ------------- ---------- �� f-� `- �� - ---------------------------------------•-------- ----------_--- (jraw existi g and required addition on reverse side) 1 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -----------__-- - --------- Pneri - - -- Owner - 1. ---------------------- (If other than FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . _ __. ' - ----------------- DATE --q{--r"_-C7- ------------- BUILDINGPERMIT ISSUED --------------------------- -------- -------------------------------------------- ---- --DATE ----...----------------------------.- ADDITIONAL COMMENTS ------------------------------------------------------------------- ------------------------------------------------------------------------- ----------------------------- ----_------------- -------------------------------------------------------------------- - -------------------------- --------------------------------------------------------------------------------- ------------------------------------------------------------_---------- ------------------------------ ----------- --------- --------------------------- -------' - - - - - - - - - - - -- Final Insy:b P Y; "✓3r3�✓�• k ------------------------••----------•---------- - ---------- --------- ------ Date . 'r:- _;- SAN JOAQUIN LOCAL HEALTH DISTRICT