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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ..................... This Permit Expires 1 Year From Date Issued Date Issued_7�.3�7 Application is hereby made to the San 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 ,......./,1- - p-,:_ •. r /_.... :: .r; .`.'..._.. ....CENSUS TRACE .. :_......... Owner's Name .._.._.. ....+.. .... _sl.�?7�?f?!SLS................... . ....N�- v ...... .. i.. n } Address fss..*.`,�....1 b.._( M. G . ... .... Phone Contractor's Name .�� .. .,, :-:License # ------ Phone . � ....f Installation will serve: Residence UPApartment House] Commercial-❑Trailer Court �- Motel C] Other ......... = Number :of living;units_____________ Number of bedrooms ...5�_Garbage Grinder ........._._ Lot Size -----------•...................... I Water Supply: Public System and name ..................•..- -- f :•--;------------ --•-•-.............---•--......... --- Priv \ P ' ate Character of soil to a depth of 3 feet; Sand❑ Silt❑ Clay j] Peat❑ Sandy Loam_ ]/Flay Loam j] _ ,.... �- ..a.,,. . - Hardpan ❑ Adobe ❑ Fill Material ---------- If yes,type ...-----------._..--•---•_-• {Plot pfd{, showing size of lot, location of. system in relation to wells,.buildings, etc: must be placed an reverse side.} NEW INSTALLATION: {No septic tank oriseepage pit permitted if public sewer is available within 200 feet) PACKAGE TREATMENT [ ] SEPTIC TANK[,J' Siz®....................... .�. .. . .................•....... Liquid Depth _.......... .............. » Capacity ...... Material .............. No. Compartments ... .._ --- T Distance to nearest: Well ................... ...... Prop. Lin LEACHING LINA [ ] No. of lines -.-_---•. .............. Length of'..eaich__lir e................ .._ ....... Total Length ............... 'D' Box Type Filter-Material __`..- :: :Depth -Filter Material ..:__..._..1 Distance to nearest: Well . ............:......... f=oundation _._........ ............ Property Line ......................... SEEPAGE PIT [ j Depth -------------------- Diameter ....-- ;-- Number ._._._-:..___......... ..... Rock Filled Yes ❑ No Water Table Depth. ------ -- ---- .........Rock Size Distance to nearest: Well .................. .._xFoundation __...:.._._._.:..... ,Prop. Line ...................... ,= _... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ............................... --} r Septic Tank (Specify Requirements) ---------• ------—------------------------ --................. .. ... ----- y—. - ---_ Disposal Field {Specify Requirements} _ ! _•. y_...1!_ - +a� Lot ........................... .. - .._...:. -----..---.- .._.__ ...... p :.(D(aw 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. Homeowner or licen= sed agents signature certifies the following: I "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any parson in such manner as to become subject to Workman's CoMpeniation laws of California." - SignedOwner . . .. ............ . ......:.................. .....: _ CJBy - -••- -------------------------------------------------- . If other than owner) F DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ......_... :... --•- . . ....... • DATE �-¢-7... -. -. ._._-.... BUILDING PERMIT ISSUED ............ : :... . ....................... DATE DATE -----=......------... _. _ ..._ ADDITIONAL COMMENTS ............... : ::.....:.. --•-----........ ------------------------------------------------------- Inspection by: --------=i;.-' Date - f" .............•--•-•--•-• ......... .........•-•--- ...... ....--•--..........--- ------------..:... SAN JOAQUIN LOCAL" k ALTH .DISTRICT E._H.13 241-'68 Rev. 5M 7172 3 M