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F,02 OFFICE USE: APPLICATION FOR SANITATION PERMIT f / (Complete in Triplicate) Permit No. _. 3.:/..4?3 ......... ...................... .............. This Permit Expires 1 Year From bate Issued Date Issued .......... Application is hereby made to the San Joaquin local Health DistrictIffor a permit to construct and install the work herein described, This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: %.. .......CENSUS TR..AC_T .........................JOB ADDRESS/ OCATION : _ Owner's Name ..------•--....... ....p....� ...... ... . ... Q.: . .. City ..., ---•.....----•... . ..........................Address - NN F^2. -- .... Contractor's Name - -- . ---.License Phone 7-- Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court 0 Motel ❑Other -.... �.l .f.S+ ._.. - Number of living units:.. A.... Number of bedrooms _#..._..Garboge Grinder ............. Lot Size Ass --. Water Supply: Public System and name --- --------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay 4 Peat❑ Sandy Loam ❑ Clay Loam ❑ nn Hardpan Adobe ❑ Fill Material`,_. .. ..... If yes, type ............................ "J (Plot plan, showing size of lot, location of. system in relation ,to wells, buildings, etc. must be placed on reverse side.) 1� NEW INSTALLATION: (No septic,tank or seepage pit permitted if public sewer is available within 200 feet,) a PACKAGE TREATMENT ( I SEPTIC TANK.1 Size-•---.��Q___ ............. liquid Depth ...-uv�.. ..... ..... Ccfpocity Type �v'�' i`_ Material No. Compartments -- ............. Distance to nearest: Well .. .�... �`_..._______---Foundation ...... Prop. Line .,_.�--- ...... ,LEACHING LINE No. of Lines ). ..._ r _ Length off each line .... .-- - _. Total Length ..._. o................. 'D' Box .✓�...�,f:Type Filter Material �fi��------.Depth Filter Material ....fc�'..' ---- ------------ Distance to nearest: Well .... r_"`..-_-- Foundation . ..... Property Line ..�` ..................�............. SEEPAGE PIT jA Depth . �.5-,�._._. Diameter .�o......_ Number _C.............. .... hock Filled Yes No 0 Water Table Depth-...._7`- Rock Size z------ ------------ ' Distance to nearest: Wel! ..._.1a ...............Foundation _...1 . ..`'�-- Prop, line ...dam.._. REPAIR/ADDITION(Prey. Sanitation. Permit# -- _--------•--- ---- Date -------------------------_ ......) SepticTank (Specify Requirements) ------- --- - - ------- -------._.._..-------......------..........-- __ --.-. ----- ........ -----.------.---. --- ................ Disposal Field (Specify Requirements) ....................................................... .........................................I._•---..- f ............. ------. I. ---------------------- - --------------- ......... -•-......-............. . .................. .................... ....__.......-... .......... �(Drdw 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. 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 7okan'sCompensation Iaws of California." Signed ....... .. . --- --- - ------- - ---- ---------- -------------- Owner By -. ._ ------- ------------- -- Title (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. . . .... .............. ............. DATE .... zO �•• BUILDING PERMIT ISSUED ... •--- DATE . .................... ADDITIONALCOMMENTS ................. . ....... ---------------•--------- ....................................._.................. .................--•---_ .---...........I.... ..._._... . . . - - - - ._........-------- ...... ............ ...............................I ...-------- ----- • ..... .....................•---- Final Inspection b -- •• .......- -------- - ------- -- ------.....Date .(.. .......... SAN JOAQUIN LOCAL HEALTH DISTRICT `q 7177 3 M