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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ?'aT. .-.:2.:.4.A....P.M............. - - Permit No. . ...•........�.. : (Complete in Triplicate) r` i ................. Date Issued .. 7a. ... 1 ............. This Permit Expires 1 Year From 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 Na. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ...: ........ ......... ........CENSUS TRACT .:.. ......... _:.... Owner's Name f� . fN �STt� Cy. _.... phone.... Address ..._..cS�y_ O. .._.'4- ta................. ........................... City ._.. . . .. .. ....... 0; . .... Contractor's .................................License # s� ,'.I ll.. Phone ...�:�r.�:�g��.�..... Installation will serve: Residence (.Apartment House,[] Commercial QTrailer Court 0 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 0 Silt(] Clay ® - Peat❑ Sandy Loam 0 Clay Loam �I j Hardpan ❑ Adobe'[t},Fill Materia( ............ 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 T ] Size.....................................:............ Liquid Depth .......................... Capacity ............. ...... Type .................... Material................. No. Compartments ...•.................. .. Distance to nearest: Well ..Foundation .....................• Prop. Line ...................... r/ LEACHING LINE [ j No. of Lines ........................ Length of each line............................. Total Length ...................... D' Box Type Filter Material ......Depth Filter Material ...........................:... ' .. yp Distance to nearest: Well ..... Foundation .......... Property Line ......................... fi SEEPAGE PIT [ ) Depth Diameter ................ Number ............................ Rock Filled Yes [Q No 0 Water Table Depth ..:................:........Rock Size .............---...........---•- Distance to nearest: Well ...Foundation .................... Prop. Lind....................... REPAIR/ADDITION(Prev. Sanitation Permit # --------------------------• Date ••---.--•.-•---••-,•••-••-••......I Septic Tank (Specify Requirements) _...., ..................................................t - ��C_H--• t � L.._ .....�."1�. 3.,:x 2 .,....t...................... Disposal Field (Specify Requirements) .._.�..d..........f.- ,e , ... ... -•-----••------•...... ......... •--------------...-••---....--- 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 San Joaquin County. Ordinances, State laws, and Rules and Reputations 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, 1 shall not employ arty person in such manner as to become subject to Workman's Compensation laws of California." Sign . ................................... . ........................:... ------• Owner rBy ... .. ..e...... . Title ..�c � ................ ........ ........ �(lty thah owner) P DEPART ENT USE ONLY ! APPLICATION ACCEPTED BY DATE .. -•-•- .. .. �............................... � . ,/� ..... BUILDING PERMIT ISSUED ...... .. .............................. ......... .....................•---• DATE l. ........ ... . .................... ADDITIONAL OMMENTS ............................... n ...........................................................•- . .•. ......... .. _......... .. ....: 4e .. _...... Final Ins ction by Da .. -�-�- ...... .. ....... . . JOA IN *LOCAL HEALTH DISTRICT 7172 3,X