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FOR OFFICE USE: ----------------------- -----4.0;4-7------------------------------------ I _0� APPLICATION FOR SANITATION PERMIT "'y (Complete in Triplicate) This Permit Expires 1 Year From Date Issued 7z-t�7 Permit No. -- ------ ----------- Date Issued z" fY' L 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 i4n�jcompliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LO ION - ,C --------- �-- -- — -------- -- ----------------CENSUS TRACT ----------------------------- -------------------------,/Owners Owner s Name --------------------------------------------------------------------------------Phone ---- Y- �----- Address----- ---------- - _----- ------------ -City ---- ------------------------------------------------------- Contractor's Name _1: a _ -Q.-I-1-1i - --------------- License #_7-__-_ Phone _____, Installation will serve. Residence [Apartment House Commercial ❑Trailer Court Motel ❑ Other --------------------- Number of living units: ------------ Number of bedrooms �-----Garbage Grinder ------------ Lot Size - ---------- ----�- Water Supply: Public System and name --------------------------------------------------------- ------------------------------------------------------ Privateer Character of soil to a depth of 3 feet: Sand E?� 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 septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [] SEPTIC TANK'[ ] Size_______%A_ _____ _— Liquid Depth ___________________________ ?kj �) Capacity -------------------- Type M. --- No. Compartments-----------^�,----�-,-_-- v Distance to nearest: Well ------------� ________________Foundation ______�_ 0________ Prop. Line --- ik5�...... LEACHING LINE [ ] No. of Lines --------- .�__________ Length of each line --------- J_ ----- _____ Total Length ___t ___-____ D' Box ------ /____ Type Filter Material/ <-_____ Depth Filter Material ______, _ __.. __-___-_- Distance to� nearest.. Well ________________________ Foundation _.__ - �_o-_____._______ Property Line __________....._....___ SEEPAGE PIT [ ] Depth --_a _`�_______ Diameter _3_'� ------ Number ---_--- - Filleg Yes [l ---No 0 Water Table Deptha Rock Size ------- 1Z---�_ L Distance to nearest: Well ---------- -_-�_____________________Foundation _._��______. Prop. Line .____�_-........ REPAIR/ADDITION (Prev. Sanitation Permit #-------- --------------------------------- Date __________________________________) Septic Tank (Specify Requirements)---------------------------------------------------------------------------------- ----------------- Disposal Field (Specify Requirements)-------------------•----------------------------------------------------------------------------------------------------------------- .----------------------------------------------- ---------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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, I shall not employ any person in such Manner as toecome a to Wor n'srCompensation laws of California." I Signed ------ - ------ -- ----- --- By ---- -------------------------------------------- --------------- (if other than owner) APPLICATION ACCEPTED BY _______� BUILDING PERMIT ISSUED --------- ADDITIONAL COMMENTS --------------- ------------------------------------------ -- - - LFina, Inspection by: ------ -- 9 -'b$ R;- 5M ---------------•------------------. Owner ------------------------------------ Jitle------------------------------------ ----- --------------------- R �AJZTMENT USE ONLY DATE .. ------------------------------------- -- -------------DATE ------- ---------------------------------- --------------------------------------------------------------------------------------- -------------------------------------- -------------------------------------------------------------------------- Date X =� -'"- - ----------- JOAQUIN LOCAL HEALTH DISTRICT p