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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7 � --, ----- Permit No. ... a .. (Complete in Triplicate) ................ ............................ .. ......................... This Permit Expires t Year Fre►nt Date issued Date Issued 1" .-7`G 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 CountyOr¢inanncg/e 4 and existing Rules and Rogulat}onsc JOB ADDRESSACICATION ...... .'.. �!?../�"� ��i�..._ca. .. .... :2)..-.-!?d�1c�......CENSUS TRACT .......................... Owner's Name .... ........ ....... . ..................................:................Phone Address ._c; .,5 .. ....5).le4- Ila.E' ...............................................City .....1�`. 1 e-Z,.7-4Fk;.1........................ Contractor's Name ...4-i_ -�................................. ....License Phone . -34.`x..:- Installation will serve: Residence Ja Apartment House 0 Commercial QTrailer Court (3 Motel 0 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❑ Slit Q Clay Q Peat❑ Sandy Loam(( Clay Loam Q Hardpan❑ Adobe 0 Fill Materlal............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 Itezmltt�d If public sewer is available within 200 feet,} PACKAGE TREATMENT j ] SEPTIC TAMC{ �Y1020,............................................... Liquid Depth .......................... Capacity .................... Type .................... Material...................... No. Compartments ...................... ' Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE ( l No. of Lines ........................ Length of each line............................. Total length ............................� 'D' Box ............ Type Filter Material ....................Depth Fitter Material ............................................ Distance to nearest; Well........................ Foundation ..................... Property Line ........................10 SEEPAGE PIT ( } Depth .................... Diameter ............. . Number ............................ Rock Filled Yes ❑ No Water Table Depth ...-•...........................................Rock Size .......---.................... Distance to nearest: Well .... . ......... ....................Foyndation .................... Prop. Line .............,....... REPAIR/ADDITION(Prov. Sanitation Permit ...... Date ..................................} Septic Tank (Specify Requirements( -----...--•.................. ............ ........... .......................� .. --. ........................... Disposal Field (Specify Requirements} 1 .� !'.. �c-F, . 15:�J...................................... •----••----•---------•...---•-•--....---•----•.................•--...._..•--.........................-•--................................................-••-•-......................... ........... --------- ------------•----............................ ----•---------- ............-.............-.............................................................................. (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that Nie work will be done In accordance with San Joaquin County Ordinances, State laws, and Rules and Regulations of the Son Joaquin Local Health,District. Hemp owner or 111cow sed agents signature certifies the following: "I certify that in the performance of the work for which this permit Is Issued, 1 shell not employ any persea in such manner as to become subject to Workman's Compensation laws of California." Signed .......... -i1 -e' -- iL ty. ' •------ Owner BY --- ------------------------------------ .......--.......................--.- Title --._..- ------ ... (If other than owner) z4FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. . . ..... DATE _ ,. .:./ .. ....... BUILDING PERMIT ISSUED ------------------------- DATE _...._._......._._............ ...... .. .. ....................- ADDITIONAL COMMENTS ................... .••........---..........-- -•....••---......_...... ...............:_ ............ .............. ---•--....._......._._._............. ............... ----•-------•----•---- ....-. ...-....... ...................... ---------- .................._..............-•---- ..._......_.... .... .............. ...........--................ ..................... ••---�---•----•/ ._-------------- -- -------------. ----------- FinalInspection by: .....................•-- ---- - •-• - -- --.. .... . _.. ... _,..._.:................_.....-.............Date .._. -......�..� . ......y ------ EH 13 2!t 1-6f3 Rev. 5M SAN JOAQUIN LOC L HEALTH DISTRICT $/?b 3M