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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: . X s 4..�.ro 1Csmplete in Triplicate) ��°-. Date issued .. �S This Permit Expires 1 Year From Dat*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: JOB ADDRESS/L TION ....... .. ................. .. . _.�...: .. - ..........................CENSUS TRACT .......................... Owner's Name .. _.. t ........... . hone . "'-.7 . ...... .. Address ............. �-.. ;.,... City .......... ... P Contractor's Name �C .......:........t celtse .�i 4, ....:. Phone 6.../..�d,�-..... Installation will serve: Residence Apartment House Commercial[]Trailer Court 0 Motel❑Other............................................ Number of living units:......1---.. Number of bedrooms ....yGarbage Grinder'-.'.; rinder :>. Lo Size .... .. .l.:z J............ Water Supply: Public System and name ........................................................ ........ L.................Private Q ,.,... Character of sail to a depth of 3 feet: Sand 0__ Silt[) Clay 0 Peat Q Sandy Loom❑ Clay Loam Q Hardpan[] -Adobe 0 Fill Material.. .. ...If yes,type... ....................... (Plot plan, showing size of lot, location of system in relation to wells, buildins,,etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit per'mtrW If-publlc sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK€ j Size..................... ............. Liquid Depth .......................... Capacity ...... ........ Type .................... Material... .............. No. Compartments ...................... o0 Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... 0 LEACHING LINE [ j No. of lines ........................ length of each line............................ Total Length ................. ....... 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ..................... Foundation ........................ Property Line ........................ SEEPAGE PIT [ ( Depth •..........:.... Diameter ................ Number ............................ Rock Filled Yes Q No (:1 Water Table Depth ................................................Rock Size ................................ Distance to nearest: Well ....... .... .................Foundation .................... Prop. Line .......... ........... REPAIR/ADDITION(Prey. Sanitation Permit# ............................................ Date .................................. Septic Tank (Specify Requirements) ............... ..... . .........................._ .. ......._................. Disposal Field (Specify Requirements) ..•, .......�40- ......................................................... ......tQ ......................................... ........................ ........................•---------------•--.........._......--- .............................._.............................................................................I.............. (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 Sat Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hems owner or Ilcen- sed agents signature certifies the fallowing: "I certify that in the performance of the work for which_I' permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of Califomia." Signed ............. ----------- - ----•-. --- ••. •-- -- . •---•.....--------.........-•-...._. Owner BY ................ .. . .. ..... ... ..........•...................... Title .........._............ ............................................... (If of er n owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY � �' `v.. .....��. . . ........................ , . DATE Z. z- 7 5 BUILDING PERMIT ISSUED .' . . DATE ........................................... ADDITIONAL COMMENTS ......:... _............................................................. ...,..,............ ..... Final Inspection b ... ............ ................................................ p..� . ............ Y= ....................................................................Date ...' ..................................... r SAN J AQUIN LOCAL HEALTH DISTRICT s;_.u.13 24t--Aa---- r..