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PVFPO�ROFFICE USE: APPLICATION FOR SANITATION PERMIT ........... Permit No. .7... (Complete in Triplicate ............... . ......... Date Issued ' tf ,-.•-.• This Permit Expires 1 Year From Date 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 ma in Compliance with unty Or fianance Nu`9 and exting Rule W!ationse SUS TRACT .......CEN ....... JOB ADDRESS/LOCATION _.. ' .._... Owner's a :..... ............. ... ...... ,. .................Phone Address : ..... ....... City ..... . ... .. ...... ........-- n a • - Contractor's Name _.. QrY4Q.... . .. ...........License # ................... Phone 6 2 Installation will serve: ResidenceAgApartment House Commercial OTrailer Court` ] Motel ❑Other ............................................ > Number of living units:......... Number of bedrooms.....•.Garbage Grinder ............ Lot Size . ............ • Water Supply: Public System and name --------------------------------------------------------- ---------------------------------------.....Private , O Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam Q 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 ize..`rL1t`1�` - ---•-•---...... Liquid Depth ........ .... ........ © .. No. Compartments Ca aci ..: .. .... Type%�— ... ... Materia)_ p .�:•�........... Distance to nearest: Well .......- .._....Fo n Prop. Line ... 4�r.. .... a ...........Total Length .....Z ............. LEACHING LINE Pq No. of lines Length of each lin --�� g 'D' Box ...� .. Type Filter Material .. ...Dep Filter Material ...4 . .. ..................•....... Property Line ' Distance to nearest: Well ... , 1.01 5 Fo ation -"""" ..........� ........._ SEEPAGE PIT �J6 Depth ..P,!;. Diameter T._.1 ... Number ....eG......_.j. ....... o Filled Yes; No Q Water Table Depth f ...•......Rock Size ..� .-• -•- ........._ 1............... Distance to nearest: Well .. ...Foundation hQ...... Prop: line ...... ...©........ x REPAIR/ADDITION Prev. Sanitation Permit# Date ..................................j Septic Tank (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. Horne owner or licen. sed agents signature certifies the following: "1 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 sub to Workman's Co sation laws of California." 1 Signed .-. , ` `� :�............................: e wlFer- BY ............................•CLAA -•--............ . aide . _ .......... .. ..................•.......................... .......t. (If other than o er) F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ,,. ... .. .. : .................. ............ DATE ...0/-./:—7K............... BUILDING PERMIT ISSUED ........................................ ....•••.... ...................................................DATE ..................... ..:..... ........ ::. ADDITIONAL COMMENT ..... .. ... . . I. ................................ ., :.:: .._.. . .: . :::.............................................. .... ....: '� ........._ Final Inspection'b. ...................:::: .... :: ...._..................- -..........................................Date .fljl. ,1.`��./V...-................. 'r ..- ................ SAN JOAQUIN LOCAL HEALTH DISTRICT 7/72 3 M r- N` 1.3 241.,6a Rev. 5M - - 11111110