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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............. .............................. - {complete in Triplicate} Pe-emit No. 23_ .- 7 Y Q......4 . .. �I... I-7... This Permit Expires f Year From Date Issued Date Issued` .........:.�,J ' 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. JOB ADDRESS/LOCATION ........ot- - __... �°! .�. ?.R. ............. CENSUS TRACT ......... c, �l�FfR1M Owner's Name ........... fq. •---------• Phone ......�—_ ..0 8 Address SFf-V� City ` e. !v-_----•- Contractor's ... I Name �t3 �� License # . 5. 3`x•' Phane :.. .. .....PtY.... -- ---------------•-••--• -------------- 1 Installation will serve: Residence [,Apartment House❑ Commercial ❑Trailer Court 0 - Motel ❑Other ............................................ ff Number of living units:......I----- Number of bedrooms ___,......Garbage Grinder .............tot Size ...... Water Supply: Public System and name __._...-Rt,_�'�('�-..........•------- ...............................Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam C] Clay Loam C]Hardpan E] 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 sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK Size....................... . - Li � } � ] • ----�'�--�= ��.T quid Depth .................. 0 Capacity ............. .. _ TYP® ---- -------------- Material------------------- No. Compartments --- ........... V Distance to nearest: Well ....Foundation Pro Line - -------•------••-------•........ ................. p. ...................... gyp• LEACHING LINE [ ] No. of Lines ........................ Length of each line............................. Total Length .......................... Type .Depth Filter Material ......:....... 'D' Box .-----.-.._. T e Filter Material ....---•-----__-.•- ...........:;.i.............•---• , Distance to nearest: Well _ Foundation = Property Line ...:.................... SEEPAGE PIT [ { Depth Diameter ........... Number _...*__.:-•..:........:..: Rock_Filled�-Filled. - .No ❑ 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) .-••-••••�[Dp �f---�Sl .__itt.r :.......... .... .................................... _...�" .3..._ ............ Prr�- {Jc�:........._..................................................... . - - - .._ •-••-•--- --- — - - ---------------------------------- ---------- {Draw existing and required addition on reverse side) ` 1 hereby certify that I have prepared this application and that the work will be done in accordance with,San Joaquin l County Ordinances, State Laws, and Rules and Regulations of the Son 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 mpensatlon laws of California." Signed Owner By _...... e4 . Title - - . .............•--- ---- . ----•--........ Ilf other than owner) D AWTMENT USE ONLY APPLICATION ACCEPTED BY -----•-•--• -•-•-- -• • . _ ...--------•------••-•--•................. DATE ........�-�•,`V: �. .......... .. .. BUILDING PERMIT ISSUED ........... .. = ......... .... . ........- '----•-•----......•-•...::.....DATE-----.-........---- ........... ADDITIONAL COMMEN .. ... . •• --- . -- ---•...... ................. ....._ -._-1---- 3............ . R ----------- .. .... ............................................................................ ............... . Final inspection by. ...: -• -••••:-• ............................................... ...........Date .......` --0------ SA OAQUIN _---- SAOAQUIN LOCAL HEALTH DISTRICT E. H.13 24 1-'6B ev. 5M 7172 3 M