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FOR OFFICE USE: ............. APPLICATION FOR SANITATION PERMIT ................ ..... 7� _.-_ (Complete in Triplicate) Permit No. ..................... . .. . ...... ....... .......... ... .............••- This Permit Expires 1 Year From Date Issued Dots Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal) the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .... ....._ �7. ..... ............ - - ..... .. ..... .....................CENSIIS-TRACT ......... ................ Owner's Name ..-.. �,�h 1.Wit ,.. ` Phone ------- Address .......... . .... .. . ... .... ....... ..............city ..,/ �►/Y .... .................. .......... Contractor's Name _... -----s.._...s..__.. r.� ...............................License .Ki 45' .. Phone Installation will serve: Residence('Apartment House f] Commercial❑Trailer Court ❑ Motel ❑Other------- .................................... Number of living units:.......... Number of bedrooms .......Garbage Grinder ............ Lot Size .7 .. .......... Water Supply: Public System and name ...-•----•-•......................._............---....._....................................................Private{ Character of soil to a depth of 3 feet: Sand❑ Slit❑ Clay ❑ Peat❑ Sandy Loom RC1' Clay Loam ❑ 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 severer Is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK j ] Size.. . .ls, ` ............ Liquid Depth ....... Y............i Capacity .... Type tv-x- !I 9q`Material............i......... No. Compartments _J de Distance to nearest: We ...20...........................Foundo0o .ad............ Prop. Line . .t"�. ........J LEACHING LINE [ ] No. of Lines --3'--------------- Length of each line-._.( .-2-j.:............. Total Length o-2l.,a............(' f-._... Type Filter Mater) el�/� Depth Kilter "orial ,� �. 'D' Box .. ..... ... ....... .../.......... Distance to nearest: Well _%If............... Foundation G/�,, -.�'C!.............. Property Line ,ll� .............-� SEEPAGE PIT { j Depth .................. Diameter ................ Number .......... ..... Rock Filled Yes ❑ No Water Table Depth ................................................Rock Size ................................ -� Distance to nearest: Well ........................................Foundation,.................... Prop. Line ............. REPAIR/ADDITION{Prov. Sanitation Permit# ............................................ Date ........... ......................) SepticTank (Specify Requirements) ..............................................................•--.............----...........................................------•--.......!! Disposal Field (Specify Requirements) .-•------•-----•--------------------•-------•--•-------....---•-------•-----.....-----------------•• -------------- ----------_--- . ------------- ........................... ....................................................................................................................................................... •-------------------------------------------------------- -................................---------------_....... -----••---•----------------..............------._..........••--.............--.••... (Draw existing and required addition on reverse side) I hereby certify that 1 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 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 ------ 4 _47 -........................................... Owner W By ---- ------ -------------------------------- ................. Jitle . . . --- . (If other than owner) FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY ----------•-- -----------------•-- ._.... ........ ........ DATE BUILDING PERMIT ISSUED .-.-•.-- -------•...... ..............................---------------_-- .....•. .DATE .._._... _..... ....----- ADDITIONAL COMMENTS ------------- •--.......------------•---•-•----•------...........-... ------------- --- -------- -------- ......•. --......- -----._.......... --------...--------•------ ..... ..---- ..................._..._..-........... ------ ------------------ ..................._. ------. ...................-..... .................................... . Fina Inspection by: ..---- ..................................................................................................Date' ... -. ... '"7. ....... ... EH 13 2!t 1-68 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7)1 3M f