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FOR OFFICE USl":.> APPLICATION FOR SANITATION PERMIT Permit �Jo. ...............' _ ... --........_. .......- .•...... (Complete in Triplicate) ` ' ,....,................. ....................... Date Issued ..........I-- ---,,, This Permit Expires 1 Year From Date Issued I 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... ._ .1__.: ------- `�`— CENSUS TRACT :----------------- Owner's Name .aL- ----------------................. Phone .. i � • -... Address city City !p Contractor's Name459' License # l c... Phone /e�bl' a Y. k Installation will serve: Residence oApartment House Commercial []Trailer Court 0 Motel ❑ Other ..,.- ....... ...........--. -..-------- Number of living units:.../..... Number of b drooms . .____.__.Gorbng Grinde:r� .... Lot Size _.., / l a.. •--- Water Supply: Public System and name ....� _ i._.__ -------•...................................•--....-- ...Private ❑ O Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe k Fill Material ............. If yes,type ............................ r (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 perrniittt°ed if public sewer is available within 200 feet,) p PACKAGE TREATMENT ] SEPTIC TANK [ ] LXIS Tf'Siz ---------------------------------------- Liquid Depth .......................... Capacity .. . Type ------- :------ Material-------------- ------- No. Compartments ....-.-•---------.---- Distance to nearest: Well .....................Foundation Prop. Line -------- ............. LEACHING LINE No. of Lines . Length of ch line .... �� /� � -- _... _... � �--- ----- ------ Total Length .f� ..........----•--..._. 'D' Box �- Type Filter Material - - ----------------Depth Filter�Material /._.--- .........._.............. Distance to nearest: Well >idV&eleFoundation ........ Property Line -:3------------------- SEEPAGE PIT ( '' Depth — ----- Diameter 1?.�Z... ---- Number . .Rock Filled Yes J No J` Water Table Depth .. T ---------- ._p.............. � Rock Size ... ,.. �.. Distance to nearest: Well _ ..(fa!r. -C_---_.-.--Foundation -__. 4... ....... Prop. Line `_.�..~...-..--...._. REPAIR/ADDITION(Prev. Sanitation Permit# --------- ---------------------------------- Date ------------- ) Septic Tank (Specify Requirements) . __. ......_,.... . --- -------------- Disposal ---- _.._... Disposal Field (Specify Requirements) , ----- f �' f I 'r......... (Draw exist• and required addition on reverse side) _ I hereby certify that I have prepared this application and that the work will be done in actor ante with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen- sed agents signature certifies the following: r "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---- .... Owner ie�7By .... ..... . Title (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE BUILDING PERMIT ISSUED ---------------------- -- ------------ -------------------------- --------•----... ... ... . DATE . ---.....---...----•--------- ADDITIONAL COMMENTS .....-................................... -- .....................-_........................................................... ...,:. ' -----------------------------------------------------•----.....-- .--.-..._-..------•- -- ----.....------._...,.-------.....-------------- :..-.---------- •-•- -_-.-_ .......................... .... ........ . . . .. ...................... ........... . • ...... ...... . ----........ . ._. C ...- ----- ------- -------------- -----. Final Inspection by. ------------ ---- ---- -- .................. -------Date ... SAN JOAQUIN LOCAL HEALTH DISTRICT 7/793 M