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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 0.......... ..... (Complete in Triplicates ............... Na. �......�: -a2�- • This Permit ExpiresTT Year Date 1"W" Date Issued ............... Application is hereby made to the San Joaquin Local Health District for o 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/LOCATI , pQQ. � - CENSUS TRACT Owner's Name .... _........,.. Addressf" ' '. .. ..........:Cy ....... .Phone ..,...... ,...........,... ......... ... ..City Contractor's Name ' r--14 ... ...License i .1�+�. e��" phone .............................. installation will serve: Residence :_ •. rtment House fl Commercial❑Trailer Court ❑ Motel []Other............•.......................... Number of living units:...... .... Number of bedrooms "....Garbage Grinder ............ Lot Size �-e^—� Water Supply: Public System and name ......................................................... _-• ....-......Private iCf Character of soil to a depth of 3 feat: Sand❑ Silt❑ Clay ❑ peat❑ Sandy Loom Clay Loam ❑ Hardpan p Adobe❑ Fill Material .....I...... 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 j Size................................................ Liquid Depth .......................... Capacity --------------••••-- Type -------------------- Material...................... No. Compartments Distance to nearest: Well Foundation Prop. Line .... ........ ......... LEACHING LiNE [ j No. of Lines ------------------------ Length of each line..........................-• Total Length 'D' Box ............ Type Filter Material ................ Depth Fitter Material Distance to nearest: Well ........................ Foundation ........................ Property Line . SEEPAGE PIT [ ) Depth -------------------- Diameter ................ Number -_--*... .... ........ ........ Rock Filled Yes ❑ No �❑ Water Fable Depth ---.............................................Rock Size 0 Distance to nearest: Well ..................... ..Foundation .................... Prop. Line .................. REPAIR/ADDITION(Prov. San#tation Permit# ............................................ Date ..................................} Septic Tank (Specify Requirements) .............. Disposal Field (Specify Requirements) . .................................... -............................................. ................................................................. ---------- ----------------............-............................................................................................ (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will Joe done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Hem& owner or il sed agents signature certifies the following: an- "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 ..-- ................................ ..•-•-. --•••-- Owner y- By ----- ---- --------------- ---------------- 1" .._._ ._... . Title :. Ok-.. -�r/e. (if other than owner] - .......... . ....... .......... FOR D PARTMENT USE ONLY APPLICATION ACCEPTED BY•.-- --... . BUILDING PERMIT ISSUED _...------•. DATE ---- ---- ........- •---- ................DATE __..._. ._......_........ _....._. ADDITIONAL COMMENTS ............................. •................. . 17---------- - Final Inspection by: ........ • --•---... _......•.... ........ .. ...... ..................... ..............Date .. y.. �cam" ............ ' � 13.24 1-bt3 Rev. 5�i .. ............. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M