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I FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i ............ -----•--------------- ------- ------- �7—� 3 ............ ....... . _ to '_r........._- (Cample in triplicate) �. . 1! o ................... ................. This Permit Expires 1 Year from Data Issued Data Issued .-aT.7.� 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. 544 and existing Rules and Regulations: - f JOB ADDRESS/LOCATION j` 7 . ...............?'� CENSUS TRACT . ...... t iOwner's Name ............. ..... .. ......,....................:................Phone ......... ..,.....................,. Address ..: .. ...... . .... City el<pna ............................ GG Contractor's Name ...-. ... License tlk .lL k ..... ..... ... . ....... 1 _..... Phone .............................. Installation will serve: Res#deuce❑Apartment House[3 Comm tial❑Trailer Court ❑ ' Motel ❑Other --. 2u7.L ' . 4 Number of living units:....../..... Number of bedrooms ..�...Garba a Grinder .' Lot Size ............................................ Water Supply: Public System and name •--- -. ...................I................ ............................................................. Privatee Character of soil to a depth,of 3 feet: Sand b ilt Q 'a- [Iay Peat❑ Sandy Loom ❑ Clay Loam ❑ Hardpan[Adobe 0 Fill Materlol �.] ............ If ye:,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 Size......:.......:::... Liquid Depth ; i Capacity .................... Type ..... .............. Material...................... No. Compartments ...... Distance.to nearest: Well -- • r...................Foundation ................... Prop. Line ...................... LEACHING LINE [ ] 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 0 No ❑ WaterTable Depth : .. ....Rock Size � Distance to nearest: Well ' .:.:�:':�..:Foundation ................ Prop. Line "4 REPAIR/ADDITION IPrev. Sanitation Permit# Date Septic Tank (Specify Requirements) ...........:............................•................. ---- Disposal Field {Specify Requirements) [/ --- ..-'---- -- ---- - - - ---••--••----....._..-.--- • . .... ....----- . ........:.... i (Draw existing and requIred•acldit#on on reverse side) . I .hereby certify that I have prepared this application and that the work will .be.done inaccordance with San Jeagvin E County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,Dislrfct. Home owner or Ilcen- sed agents signature certifies the following: "I certify that In the performance of the work for which this permit Is issued, I shall not empfoy any person in such manner ! as to become subject to Workman's Compensation :laws of California." } Signed -------------•--• ---•---- Owner �j � BY ------ - - J = .. ... Title ..�-dtiy.. .... (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .G. . : ............ ......•-------------------------:--:-- -:,_____DA7E:.S.,..?.j .?. [__.....,..... .BUILDING PERMIT ISSUED --------------- ....... •------------....................----DA3f ...... ADDITIONAL COMMENTS ------------------------------------- -- ------- r -------------............------.....-------------------------------•-- I ---------•---•------ ----=--------------------------------------------------------------------............. .........----.......------ .. .. ........ f ------------------ ------------------------- ---- , { r f=inal Inspection by: .- ..- - _.. . - : .. -r��.}........... .... Date . . ......... J EH 1.3 2! 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M t y - i