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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. �.l.. ._ IComplete in Triplicate) ................ .1..!..._.................... ... This Permit Expires'l YeorJrem DAte Issued Date Issued .-` 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 omplionce with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..._ -- _...�/ ... .. . ....CENSUS TRACT ......... ............. Owner's Name . qG ----- t 3.6.7. .. ...,. ...................Phone ......... .......................... Address _. ._ . . ( . . �..... .......... ..... City ......... ..._ ... ............_ . Contractor's Name --- ..........................License# l....31 .�� Phone ��.-r77J40 Installation will serve: Residence 0 Apartment House[-] Commercial❑Trallw Court JJ Motel ❑Other............................................ Number of living units:-../....... Number of bedrooms _.3......Garbage Grinder ............ Lot Size ...042^ =............... Water Supply: Public System and name .............................................................................................................Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy loom❑ Clay Loam Z____... Hardpan❑ Adobe 0 Fill Materlal ............ 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 I ] Size....../...A.6.0...................... liquid Depth ..... ................... Capacity C Type ...C�'--rl----- Material...................... No. Compartments -.2............... Distance to nearest: Well ... 0......................Foundation ..1Q............. Prop. Line ....... ........i LEACHING LINE [ ] No. of lines -------................ Length of each line.... e----......... Total Length A.,7/_-2............ D' Box Type Filter Material . .......Depth Filter Material ./. .................................. Distance to nearest; Well ........................ oundation ........................ Property Line ........................ SEEPAGE PIT [ 3 Depth .................... Diameter ............. Number ............................ Rock Filled Yes ❑ No 0 WaterTable Depth ................................................ Size ................................ Distance to nearest: Well ..._.........._-..Foundation .................... Prop. Line .............. REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ...................................I �3 SepticTank (Specify Requirements) ......................................................••--•----............------.................._.......................---................ Disposal Field (Specify Requirements) --------•-------•...........................................................•-----------•------•-•---.......................---•--... tb ------------------------------------------------ ........ .................................................................. ............._...................-•---........................... ................. ...........-......... ------------------------ ....... ..................._............................................................................................ (Drove existing and required addition on reverse side) 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health:District. Henle 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 to become subject to Workman's Compensation laws of California." Signed ---------- ----------- --- ---Iner) ------------------•----------------•------_-------------- Owner By (I t er an FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _... _.... DATE -- - ------ --- ----- ------- - ----- ---- BUILDING PERMIT ISSUED ..._-- -- -----:..........DATE ._-_ --_-- ADDITIONALCOMMENTS ------•.. .......... ................ .•---__----_-_- ---------------------•----...-.._...._.--.---- --•-- ................._..--•._....-•---........ ---- ....._.......... ....... ........ ........... ................____----- ----- ................ ......... .....--.......... ......_ ................... .......... i . ........... .. .................. ---- .......... ---. . --- ..-. _..-- Final Inspection by: ... .. �,........ -------- --------- Date . . . .-.� �,1 ...... EH 13 2h 1-613 Rev. 5m N SAN JOAQUIN OCAL HEALTH DISTRICT 8/7h 3M