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FOR OFEkCE USE: APPLICATION FOR SANITATION PERMIT ---------------- ------------------ ------- Permit No. .-7�--�J, (Complete in Triplicate) ___ --------------------- This Permit Expires 1 Year From Date Issued Date Issued -- ------------- ' Application is hereby made to the Son 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. 54 and existing Rules and Regulations: , r _ JOB ADDRESS/LOCAT N . s -)7- 4_ -------- ---------- CENSUS TRACT Owner's Name ------------ Phone e� -- g Address -----.�__;_r,--- f----------lit�'c Contractor's Name ------- -- � '-- ------License #--l�17_7 Phone Installation will serve: Residence Apartment House,l Commercial ❑Trailer Court ;❑ Motel ❑Other ---------------------------------------- Number of living units:.--/ ---- Number of bed ooms -g -------Garbage Grin r All'i_ Lot Size _.�� - --- ---------- -- ---- Water Supply: Public System and name ------ ----------- --------•---------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sandf] Silt❑ Clay. ❑ Peat❑ Sandy Loam ❑ Clay Loam .E] Hardpan ❑ .. Adobe k Fill Material ---------------if yes, type -------t-----------------_ ; (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 seepage pit permitted if public sewer is available within 200 feet,) , PACKAGE TREATMENT { ] SEPTIC TANK![ 1& 7 Size------------------------------------------------- Liquid.Depth --------------------------- Capacity -----------------.-- --------------------.-----Ca acit Type -------------------- Material------------------- _ No. Compartments ------•--------- ---_ { Distance'to nearest: Well -.-----_---------------------------Foundation ------------- Prop. Line __-.-------_.:_-_----_ ' LEACHING LINENo. of lines ------/--------------- Length of each line___--�W- `------ Total Length ......... 'D' Box,. ---.- Type Filter Mafierial - -G, -Depth.Filter IMaterial`-.AF----------------- --------•._•__._ Distance..to nearest: Well &2 AW 4- undation ---/a _-----_ Property Line _-� _._- SEEPAGE PIT Depth _ , ---- Diameter ---------------- Number ------------------ --- Rock Filled Yes No.i❑ Water TablO Depth ------, d_,. -----------Rock Size ___12------------------------ Distance to nearest: Wellm"Q-_-�.�- 7--------Foundation -- d-----_-_-- Prop. Line -- 5-___--_........t r �` -1" REPAIR/ADDITION(Prey:�Sanita#ion Permit`# -°--------------- --------------------;- Date ---- _-------�-------------------) � '- Septic. "ank (Specify Requirements) --------------------------------------------------------------------------------------------------------------------------- ------------------- Disposal�`Fie1d (Specify Requirements) - � ----�-gid- - - -- ------ --------------- ---------- � -� t t{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- se certifies the following: sed agents signature : u g "I certify that in the performance of the work for,which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----------- --------- ------------------ --------- Ownery ---------------- �' ------ Title --------I . BY ----- ---------- < - z �L--` 4 (If other'than owner) FOR DEPARTMENT USE O LY APPLICATION ACCEPTED BY -_ -- --- ---------------------------- BUILDING --------------------------BUILDING PERMIT ISSUED - ------------------------ --------------------------------------=--------------DATE -------------•----------------------------- ADDITIONALCOMMENTS ---------------- ----------------------------------------------------------------------------------------------------------------------------------------- i --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- ------------------------ ^ --d -- ------- S-_ -- Final Inspection by: ------ /f ---------------------------------------- Date -.3 17--- SAN JOA UIN LOCAL HEALTH DISTRICT # E. H. 9 1-'6$ Rev. 5M