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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT .............. . ....... ......... . ..... ..... Permit No. (Complete in Triplicate) -••��---•---•--••• • _...... ....................................... ....... ..................... This Permit Expires 1 Year From bate Issued Date Issued ��-.a.1... Application is hereby made to the San Joaquin Local Health District for a permit to construct end install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION� ........ ---- ..CENSUS TRACT ........ ................. Owner's Name ..- ra ..... ........... ...... .. .....-- ...:--- Phone .......... .........-- ------ .......... Address z. . .... 7 ------ city City -----•--- .................. License # , � a Contractor's Name . 1.4 c.��!..... Phone .............................. Installation will serve: Res idence-IJIApa rtment House❑ Commercial ❑Trailer Court 0 Motel ❑Other - --�J..___1- ^-L- Number of living units: . �... . Number of bedrooms .....�'�.'•_..Garbage Grinder . .......... Lot Size ....................... Water Supply: Public System and name ............................. ...... ---• - ............. Q� Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan k Adobe E] Fill Material ..... . .. If yes, type ............ .... ....... . (Plot plan, showing size of lot, location of system in relation,to wells, buildings, etc.' rnust be placed on reverse side.) NEW INSTALLATION: No septic.tank or seep ge pit permitted if public sewer is available within 200 feet,l PACKAGE TREATMENT SEPTIC TANK kf Size.. j � � �!�--.�..9...1�..✓�..---...... ------ Liquid Depth .�7L...................... Capacity ypeMaterial...' N^- -.- No. Compartments ...2... •........� Distance to nearest: Well ��?.1. ............Foundation ... �..... ...._.. Prop. Line ......._ ....... LEACHING LINE [� No. of Lines Length of. each line '' Total Length ... .. . D' Box . Type Filter Material --.:. --_!Z.-. :-Depth' Filter Material .../` ."................. -- ..................:..... Foundation �.f�-........ _. Property Line - .. 1 Distance to nearest: Well p ty _..:�................. SEEPAGE PIT ( Depth �- 'S.�. Diameter _.__ Number ... _. .. Rock Filled Yes Er-__'No ..��.. X.. '� Water Table Depth .. ...............��?...� Rock Size ,............ . �....._�......... --1' Distance to nearest: Well _.. _1..V.4. .-,._.._.i._Foundation ... .... Prop. Line .._... ....- REPAIR/ADDITION(Prev. Sanitation Permit# _...... ... ........ ...... .............. Date _...._.__.._............ ......... Septic Tank {Specify Requirements) -------I——----- -------- ..............__........I—......I.. ......... ..._.-......... ....... Disposal Field {Specify Requirements) ------- .................................. ... ....... ..... _. .......................-.----.---- ------------- --- _. ...._.._ --...._.....------ -----..---------....-- (Drdw 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 lic*n- sed agents signature certifies the following: "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 C .pensation laws of California." Signed . . ........ ----. Owner By .............. ....C � Title .e (if other than o FOR PEPARTMENT USE ONLY APPLICATION ACCEPTED BY C. •� � �_ DATE //-- 1 7 _.._. --.. .... ................ BUILDING PERMIT ISSUED . . ... ..DATE . . ................ . ............--. ADDITIONAL COMMENTS - - - - .. . .. •-_..............• -•..._._...._..._ . .................................... ................. •---•-- •. . .. . ------ --------------... ... ............. --. --- -------. .... ....... ......................... ..-----------.. ------------------------. -------------------- ------- Final Inspection by: �. ................Date SAN JOAQUIN LOCAL HEALTH DISTRICT F_ H_ 1-3 24 1.Wl R.,,- SM "" 7/723M tf