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FOR OFFICE USE: ............I.............. APPLICATION FOR SANITATION PERMIT _ (Complete in Tiiplicatel Permit No. .7 s� aThis P&rmitfxpires 1 .Year From Date Issued flats Issued 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: CF-f- JOB ADDRESS/#OCAT€ON ! --.....CENSUS TRACT .......................... �, .- . . . / Owner's Name ....Phone . Address ................. 777_... . ............... . City ..................... �'..... Phone Contractor's Name ... .-- -- ..License # ........................ ... ...............•--.......•--- �;�,3.. l :j, Installation will serve: Residence ❑Apart nt House0 Commercial❑Trailer Court MotelQ Other......... .......•-•--.. ................ F Number of living units:,..---- Number of bedrooms ......_Garbage Grinder ............ Lot Size .... . _. . ... ............ a Water Supply: Public System and name ................................... private ❑ ......... ............-- Character of soil to a depth of 3 feet.- Sand, Silt] Clay O Peat❑ Clay loam ❑ "l 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 240 feet,) PACKAGE TREATMENT [ I SEPTIC TANK{ } Size----- A... ....X.ld Liquid depth Capacity �- e-�� YPe ----- M - T � ....•�............... ' --� .. aterial--------------_---... No. Compartments ...... Distance to j nearest: Well . 0.0-------_- ------•Foundation ---ZZJ............. Prop. Line .... ...0?.�D.. LEACHING LINE [ No. of Lines .._ --- ----------- Length of each line..... . .............. Total Length /170.......... 'D' Box ... ------- Type Filter Material ---------•---_----Depth .Filter Material ............... .. ..........................2 Distance to nearest: Well ......._............... Foundation Property Line SEEPAGE PIT [ Depth -------- --------- Diameter --- ------=----- Number ---.... ......- • - -..-•-...-.. Rock Filled Yes ❑ No C1� Water Table Depth ---- -•-•----------------- - ------ -•-•.....Rock Size --------........_.. ............ s Distance to nearest: Well _..................................... .Foundation .................... Prop. Line ...........:.......... RIkPA1R/ADD1TlON{Prev. Sanitation Permit+# -.-----------------•------------ ------- Date ..................... ) I Septic Tank (Specify Requirements) .-....••------•------•_---- _--- ------ ------------------- ----------------------------- Disposal Field (Specify Requirements) -__.__•_.._.._-.. ------------------------•--------- • -------------------------- raw 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,Disirlct. Horne owner or licen- sed'agents signature certifies the foilowing: "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 - --- --- - - Owner ------------- - By ......... �� !`'l!L Title .... - i of er than owner) . - FOR DEPARTMENT USE NLY APPLICATION ACCEPTED BY ------...•................ � i BUILDING PERMIT ISSUED --------------•------•-- QATE .,./0,- 7 . ADDITIONAL COMMENTS --------- •---....-.. .- ••---•----------------- ----------------------- ------ --•---........DATE .,.... ..............._......... . ._ ...-----••--- ------------------------ 1 -------------------------------------------------- ------- .. ----------••--------•...-..........•----------•-----------..-------...._---------..........._...---..... final Inspection b p y: .................... .. r...-.................- - •-----•-----•----•..------••------•--•-•.......................... ... . '�...._..Date -././r�L-�S_......_..---�-----•--- EH 13 2 1-� l�ev. SAN JOAQUIN LOCAL HEALTH TRICT 8/�h 3M