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FOR OFFICE USE: i FUR 01-HLt USr: APPLICATION FOR SANITATION PERMIT ------ (Complete(Complete in Triplicate) Permit No. . ,---- ..... -� Date Issued./:7...... This Permit Expires 1 Year From Bate Issued l 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 Ruies and Regulations: JOB ADDRESS/LOCATIO <✓.L_ � LCI . . ----- -------- ... ..........CENSUS TRACT........ Owner's Name - - -r . Phone p - .... Address - 6 7 2- / 44fzer L .. City Zip----- --- Contractor's Name . License PhonedQ�_� _.. . Installation will serve: Residence Apartment House Commercial ❑ Trailer Court IW� Motel ❑ Other_ ... ...... Number of living units: . ....._.... Number of bedrooms__ Garbage Grinder_..._..-----Lot Size __�. ----- - Water Supply: Public System and name . ................... _ __ ---- ------...Private Character of soil to a depth of 3 feet; Sand ❑ Silt ❑ Clay ❑ Peat Sandy Loam ❑ Clay !oam ❑ 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 i Liquid Depth Material..-- No. Compartments._.___ . -.-.. --.....Capacity Type -- r Distance to nearest: Well ---- ...�(} _r.. ... . _____ Foundation .._10.f.f. Prop. Line _51 ...... - ----' r 17 U � LEACHING LINE [ No. of Lines �'- ---- Length of each line ...... �.._.._.. .. Total Length 'D' Box Type Filter Material .90<A- Depth Filter Material .. ..f. __. --------- . . . --- . r 4— Distance,to nearest: Well__.... Vim. . .. ._.._ Foundation.------ --.......Property Line.... ... - -- SEEPAGE PIT Depth _ -J Diameter----9P _ Number -2/ Rock Filled Yes Xf No Water Table Depth __ ...... --. ----- ----.Rock Size. . -- - r rt- S ......._ Distance to nearest: Well........ _ ----------Foundation._.... � Prop. Line . REPAIR/ADDITION (Prev. Sanitation Permit#..... .................. -- - ----_.Date-- _- ....._.__.. ... Septic Tank (Specify Requirements).... . . ...... .. . . - Disposal ie {Sped y Requirements . .................... . . (Draw 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. Home owner or licensed 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. .. - ...... Owne-r By.......... .. . . ..... .. . . �. .. - Title ------- _ - - f other than owner) F RLART NT U ONLY APPLICATION ACCEPTED BY--- __ .. _ DATE . DIVISION OF LAND NUMBER ....... DATE....- ADDITIONAL COMMENTS _.. . . - - - ----- ---- - - - - --- - Final Inspection by; - -.Dated EH I3 sa SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 keV. 7176 3M