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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ....................,..._.. ItoPermit No. .:��c�(Complete in Triplicate) . .................. ..........................:........I.._................. This Permit Expires 1 Year From Date Issued Date Issued .. ................. Application is hereby made to the San Joaquin Local Health District for a permit to constructand install the work herein described. This application is made in corn liance with County Ordinance No. 49 and existing Rules and Regulations: JOB ADDRESS/LOCATION /.1.. _ � - i ._�-. . ...................•---./._ �.G.,� .._- ---. ....._..CENSUS TRACT _....._...._.............. :Owner's Name........_... i C ............w -.= :- ..Phone .0.. -3.�� _ "Address ✓ -------------------- Phone City 1.�__`� ��.-----� CSS- ----- ----- . ... ' Contractor's Name .. -. /fry►^ ... License # . Phone installation will serve: Residence par meet House❑ Commercial ❑Trailertourt ❑ t d ._. Motel ❑ Other Number of living' units:.,,.._.....,.. Number of,bedrooms .._.---_-..- e,Grinder .units: 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, Plot plan, showing 'ize ;of,- lot,. location of system" in relation to.wells, buildings; .etc, most be. placed ,on reverse sidlo.) l NEW INSTALLATION:' (No septic tank or seepage pit permitted if public sewer is available within 244 feet,) ; PACKAGE TREATMENT [:] SEPTIC TANK-T ] : : Size.............................. Liquid Depth :......:...............[...�a Capacity ............Type __.. Material __ ;. --- .--- CompartmentsNo. ------ ---... OQ Distance to nearest: Well ::. ...........:.... Foundation ...'----------- - ..... Prop. Line L., LEACHING LINENo. of lines "� •-tt— E' '.. f. ...._.. Total Length . ..................� { ]- � � .. Length of each Ene . D' Box' . .. .'Type:Filter-Mbferial7:7`--------- DeptFi Fitter Mdterial; ... ' _ ........ ....... ...... 1 Distance to nearest: Well t .. ......._. Property Line ---- Foundation ... ..... .. . SEEPAGE PIT [ j;. Depth --- Diameter, -:--.------ Number-;: Rock Filled Yes No s Writer; Thie Depth Rock Size. ' Distance to nearest: Well .......... ;...._`....Foundation Prop.: Line ...........:..... REPAIR/ADDITION(Prev. Sanitation Permit,# ._;_____ :......... _ Date .. ! Septic Tank (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. Ho'm►e 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 Workman's Compensation Icws of California." t Signed Owner By ....: .� 9V ............... title ... ....................... ................. /�' f o e than owner) FOR D A TMENT USE ONLY .. ._.._. .�.^. _�._. .� ^. . _ .... _. APPLICATION ACCEPTED BY ......- ��., DATE ............ �`3. # DATE ADDITIONAL OIMMENTS..-,:._........._.. -•------- ----------- .._. ................--._...---------.__................... ..........•...... ........ ............_.-. ----..----=---- . ................. ..... ... - ----- -- Final Inspection by: ..------- ... . Date ...... .'-' 2r ---.--_�... ....,, - SAN JOAQUIN LOCAL HEALTH DISTRICT