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FOR oFFiCE USE: APPLICATION.FOR SANITATION PERMIT iComplote in Triplicate) Permit No ............................. This Permit Expires t Year From Date Issaed Dobe 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 mode complio with unty Ordinance No. 549 and existing Rules and Rogulotions: JOB ADDRESS/LOCA ...... ......................................................CENSUS TRACT .......................... Owner's Name .--.. ......................................I.....................................phone .............. Address - -•....... .... .................... . .... ...City ................_.................d........ Contractor's Name .__._. •----- -- -- --��... . :�c � ........License #�.��.�.� 1.. .. Phone • --51� Installation will serve: Residence❑Apartment House mmercial Mrailor Court 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❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam ❑ Hardpan❑ Adobe❑ Fill Material ............ If yes,type............... ............ (Plot plan, showing size of lot, location of system in relation to-weils, buildings, etc. must be placed on reverse skfe.) NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT f ] SEPTIC TANK ) Size... --. ... .0........... Liquid Depth .. .................9, Capacity - - Type *aterial..-- L 17. No. Compartments ....'r .......... 1 Distance to nearest: Well ......... .............Foundation .-Le........... Prop. Line 7.e ..........� LEACHING LINE [ ] No. of Lines -----A.............. Length of each line...... .............. Total Length .............7 'D' Box .../-__.. Type Filter Material ....... Depth Filter Material ....J.�.............................;" Distance to nearest: Well ........................ oundation ......................... Property Line ...................... SEEPAGE PIT O Depth -------------------- Diameter ................ Number ---------------------------- Rock Filled Yes ❑ No ❑� Water Table Depth ......................... ......................Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ...-•_....... .................... SepticTank (Specify Requirements) ------ -------•--.. ---------- .......-----................_...-•-.................._....._..............................._................. DisposalField (Specify Requirements) ------------------------------•---•--•-•---•---•-•-----.....--•------------.....------...-----...------...-••........................ ---------------------------------------------...................................... --••-----------------•----•--•------•-•------•--------............._......----•------ ......................I......... --•-•------------------------------------•-----------------------------------------------------............-.............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 Regulations of the San Joaquin Local Health,District. Hem 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 shalt not employ any person in such manner as to become subject to Workman's Compensation taws of California." Signed _..- 40i -- . ... ....................... ... •. ....... Owner By ................ _fir-?f -- -----. Title ----------- -------_........------ •-•-------- ............ --••------ jlt a o n�F) FOR DE RTMENT USE ONLY APPLICATION ACCEPTED BY,VX •--•--•-- .__.... DATE .__a'"3 -�6. .........----- BUILDING PERMIT ISSUED ._.. ADDITIONIAL OMMENTS .._.. � -._ _ z :.:. N ,.... ice .. Ar ''lG✓�G�" Gtr?/�Grz ;�y EG�p iT it 17 _ Final Inspection b r: � _...-•-----••------------- -------.-.-. --- -.-- ----------- �: ::.:....................... Date .. ::5''7 EH 13 2!t 1--613 Rev, 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h ..-.M.._.... / 3