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FOR OFFICE USE: .......... APPLICATION FOR SANITATION PERMIT ' (Compal*In Triplicate) �7 .�� -....-•----`•��••�►- �--= � permit No f.�J .......... ...................••-.......... ............. ......................................................... This Permit Expires ? Year From Date Issued Date Issued ..-��.._�_:.76 Application is hereby made to the San Joaquin Local Health District- for d 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: JOB ADDRESS/LOCATION . .. ...._.. ... CL_l.4/_e.................... f CENSUS TRACT .......................... Owner's Name ..............: ,.............. ......Phone . ............. Address Z7 .--- '1:... 12 :........_ City : ...-------- ..---- . � �....................•....... Contractor's Name -- ----'---- --••--• ......................................License # .--•••--•....... Phone .Z/. Installation will serve: Residence j�artment House Commercial❑Trailer Court D Motel ❑Other............................................ Number of living units:-------- ... Number of bedrooms _...........Garbage Grinder ............ Lot Size Water Suppl . ublic S ste and name ................ ----._ ....Private E]_._.-..__............................... ...... Character of soil to a depth of 3 feet: Sand O Silt❑ Clay Peot❑ Sandy Loam fl Clay Loam ❑ Hardpan ❑ Adobe❑ Fill Material ............ If yes,type ............... ............ (Plot plan, showing size of lot, location of system in y relation to wells, buildings, etc. moat be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT j ] SEPTIC TANK f ] Size-_---- :--_- Liquid Depth Capacity _-- ----- Type ... -_----_-- Material-----•-•-•......... o. Compartments Distance to nearest: a ........................ .... oundation ...................... Prop. Line ...................... r LEACHING LINE [ ] No. of Lines ........ Lengt ch line............................ Total Length ....... 'D' Box _........... Type Filter erial .................... th Filter Material .....-...................................... : Distance to nearest: .........I...... Foundat_ions__-__-_-______-_------.Property Line ..................... SEEPAGE PIT ( } Depth -------• ---------- Diameter ................ Number ....•-•-_................... (tock Filled Yes ❑ No Water Table Depth -•---•----------•- ---•...................Rock Size ------....------................ Distance to nearest: Well ........................................f=oundation .__................. Prop. Line ....................... REPAIR/ADDITION(Prev. Sanitation Permit+# ............. ._......._._. Date .................................. , Septic Tank (Specify Requirements) .....-•--------•- ...... ...... .. ..... Disposal Field (Specify Requirements) .....: �. _._.. . ....... ----- • -----••---------------------...........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. 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 becom� ons Compensation laws of California.,, Signed -r'Q. � - _----- Owner BY ----- -------------------------- Title-•------ ................. -----•------. . �-(if other-than owner) FOR DEPART U ON Y APPLICATION ACCEPTED BY ............. ---- --- - - - -•-- :---------..... DATE ..,.r -c�' �._................_.. BUILDING PERMIT ISSUED DATE ADDITIONAL COMMENTS ......�_ _ _.o - - • -- y,, ,r ►{ 4 wtw... _ _�� ; --/- ------• Gam-----�......--•--..... ------- M N ------------- ------- --`-`-=` -• 'r '_ T ------ - -- - ---------------------------------------------------------- ------------•-----_----- -- ------_.--•------_--• --............. ------------ - --- -----------------------------------•------- ina Inspection �y: .. ---_.-Date ----------------- ----------------- EH 13 2a -6f3 Rev. SAN JOAQUIN t_OCAL HEALTH DISTRICT 8/7h 3M t` -