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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............... .. ....... .. .___- --.... ---- Permit No. ..7.s �� \ ................ .... (Complete in Triplicate! . ..................... This Permit Expires t Year From Dote Issued �� Issued .1..�..-/;7,.�S Application is hereby made to th aquin local Health District for a permit to construct and Instal) the work herein described. This application is made in complian a with County Ordinance No._549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ....... .. .. ... _ .. .... ...................CENSUS TRACT Owner's Name ... . .�'! lL . ...... ..."" " ... . ... ........................I..................... one .,... ... ............ .....:. Address �'.� -�..;�- . . .. .. .- ..-.. �� . • . ..... city Contractor's Name t'1� . . ............License # .......... Phone Installation will serve: Res: ence0A House Commer ❑Apartment Commercial cal❑'frailer Court 0 Motelr]Other........................................... Ae. Number of living units:-.- -----_ Number of bedrooms . ......Garbage Grinder ............ Lot Size ....... .. ti F- .. Water Supply: Public System and name ......... ..........................................•---......................................................Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Cloy ❑ Peat❑ Sandy Loom fl Clay Loom 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..... �,.,�g /o......... L utd De Capacity -; �--� Type Material ............... No. Compartments ... . ........... Distance to nearest: Well .....le-0--------_---------Foundation .../.&'?............. Prop. Line ..I LEACHING LINE [ ] No. of Lines .....-.9 ............. Length of each line........�.,p_........ Total Length .............. 'D' Box .......----- Type Filter Material ....................Depth Filter Material .......................................,. Distance to nearest: Well ......162V...... Foundation ...... 0........... Property Line .' .... SEEPAGE PIT [ ) Depth�„�.7X.0Diameter ............... Number .......V............... Rock Filled Yes No �[] Wf f..Water Table Depth ................................................Rock Size ...... .i ........ ........ /1 •� Distance to nearest: Well ....1e_0......................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ..................................) SepticTank (Specify Requirements) ............................................................................................................................................. Disposal Field (Specify Requirements) ------------------------ ------------------•-----------...------......------------------------...... ..---------.......... ......... ------------------- --------- ---------------------------------------------------------------.............................................................................I........................ ---------- -- ---------------- --------------- ------ ---------- ------...............-............- ....... ---•---------•------•-----..........-••-•-------....--•---•---..................... (Draw existing and required addition on reverse side) 1 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. Hente owner or licew sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to Workman's mpensation laws of California." Signed -- .------- -- -------- Owner BY -- ----- - '�- Title ------ --- - (if oche than owner) FOR EPART_MENT USE ONLY ' APPLICATION ACCEPTED BY --.._~-==N .. -....._ ------ --^ DATE�'(r.,�.��.. .. ..... .... ... ------. ---- - BUILDING PERMIT ISSUED - - - -•---•----..: - ...........DATE - ADDITIONAL COMMENTS ...._..... ............................ .........•-------..........---- ----------- ----- ---- ...._. - - --------------------- -------------------------- -------------------------------...--.-............. ... ... ..................... ......... , _. .G._.....__... .. .. Final Inspection b : ..--- . - ---- -- - -Z_ •-----. Date p Y -.I.- _ - - — -- EH 13 2!i 1-68 v. 5�1 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M