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FCR OFFICE USE: APPLICATION FOR SANITATION PERMIT � f7V Permit No. ..................... ........... ..._..................................... (Complete in Triplicate) ................. ...V• ............................ This Permit Expires 1 Year From Dote Issued 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION �..1,1�Q. ..,. U. Tf !!..../.cam .....................CENSUS TRACT .....................� ... =- ••.Phone . - ..... Owner's Name .... 1. 1-.... ./rC/ .I...SL .�Ct�.................................. .........•--.... Address ..154.#2V........................................•---•-----•--..................---•--....... City ....5 �.�CT�I�......................................... Contractor's Name .l! .. %�TIL`�..%�f/ i ,. ',...................License # f.��. .... Phone .��c l• tiri.C, � Installation will serve: Residence [,'Apartment House❑ Commercial [:]Trailer Court Motel ❑Other ............................................ Number of living units:..../...... Number of bedrooms ....2-....Gorbage Grinder Lot Size ../--Q ............• Water Supply:f Public System and name ........... Private ❑ .� Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ Hardpan ❑ Adobe'[I 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 QQ Size. . Liquid De th .1e."......... Capacity ./,40......... TypaJ' , ✓Material r` G No. Compartments .. .. ............... Distance to nearest: Well .. ........................Foundation .f.,C7............... Prop. line -A ................ No. of Lines ....rt .............. Length of each line..... Total Length ..�'zr •.•_•.-••••-•• LEACHING LINE �•' •" ' •"•� •• ' [ - .G`CA Depth Filter Material .-Pt................................... LA 'D' Box �.E.:f.- Type Filter Material �... ... p /.O. a Line ,,t �"................ ............. Pro Distance to nearest: Well ..... o............ Foundation Property Diameter Number ............................ Rock Filled Yes ❑ No ❑ SEEPAGE PIT [ J Depth .....:............•- ................ Water Table Depth ................Rock Size ............................... Distance to nearest- Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................) .......................... Septic Tank (Specify Requirements) .............................•••.................................` Disposal Field (Specify Requirements) ..................................................••.............••-•....••••- ..............................................................: ... ------........................----.......--•--.........--•--....---••-•........................ ......-•--•----------------•----.........................1:z,...J.'...--•---•----............................._.................---•-.......................................................... ......... (braw 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 Regulati6nt of the San Joaquin-Local Keatth District. Home owner or licen- sed agents signature certifies the following: person in such manner "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any p as to become subject to Workman's Compensation laws of California." Signed ....................................... .................. Owner ..................... .. ...:........ ............. Title .. .................. (If other than o er) FOR DEPARTMENT USE ONLY p APPLICATION ACCEPTED BYA ....................... DATE ........-1"°�`...•� BUILDING PERMIT ISSUED ... ........................................DATE ........................................... ADDITIONALCOMMENTS ..........................._........................................................................................... .. ......••••............. ..........Date ........ ................. .... ....... Final Inspection by: .. . . ................................................... SAN JOAQUIN LOCAL HEALTH DISTRICT L3 241.'68 � 7/72 3 M E. H. 1•'68 Rev. 5M - _