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I FOR OFFICE USE: I APPLICATION FOR SANITATION PERMIT E {Complete in Triplicate} Permit No. .-7.......CCS! ...................... ............................... ......................... 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 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/LOC fION ..CENSUS TRACT ............. :........... Owner's Name ..... ---•-•........ --•••••.. .....................Phone ..................................... _4 ..................................... Address ...------- ?.� � �...... .__.... c Q- �:_._ City . y :.. Contractor's Name ----- 2 ..... ....License # 1Jff.5X- Phone ..........:.........:.......... Installation will serve: Residence partment House Commercial❑Tralier Court Motel ❑Other -- .......•-••......:............: .: Number of living units ..... Number -of bedrooms .�--_Garbage Grinder .._...._._ Lot Size.......................:.................... : k Water Supply: Public System and name ......................................... --•............... ............ ----•-. Private Character of soil to a depth of 3 feet'. Sand'❑ Silt'[ 1 Ciay C] Peat[] Sandy Loom Clay Loam❑ Hardpan ❑ Adobe ❑ Fill Material .......... If yes,type ............................ {Plot plan, showing size of lot, location of. system I; relationtowells,_buildings,_etc._must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepprge pit,pe6itted if public sewer is available within 200 feet,) j PACKAGE TREATMENT [ ] SEPTIC TANK.t Size:.. ,1 �. .._I___�_ ... ...1_. Liquid Depth ...CI...............►� Capacity . . t?.. Typ c -A . Material.___,___ _ s_ No. Compartments .. .....:..._6 ► .. Distance to near t: Well ......•.. .tV- . -- ....k..Foundatior n_:._J..h.. - Prop. Line ...Z ...........t � LEACHING LINE [ No. of Lines ------c�:J, � ... ........... ___ Length of each line._____ � . Total Length .S`��_..�d........__._.� j 'D' Box ...T a Filter Material mss._. 4 '� Type �:..'°':Dejitli"Filter Material .....�._. k Distance to nearest Well' T. Foundation .....LQ._�_- .. 'Property line,n J { .. "va SEEPAGE PIT r Depth -Diameter `''' Number .. Rock Filled ..Yes ❑ No Q ..........A.--- ..•• Water Table Depth ------------------------ -µ ................Rock Size ............I.......... ------• _ ._.. . .� Distance to nearest: Well _------________ ...Foundation .... Prop. Line l f ..... REPAIR/ADDITION(Prey. Sanitation'Permit�#c: .-� :.: .::`....' ..:_.: Date .... ..........................I 1 t I " Septic Tank (Specify Requirements) ................•--------. .......................................... ------...........__..............._......... ._...----•------- Disposal Field (Specify Requirements) _ ............ ................................••---..._...._........_.__...----•._._.._._.._....................._.__..............._f....._.......------------......._.._.__...._................................_..._. ' r } (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-Son-Joaquin..Local Health District. Home owner or iicen- zed agents signature certifies the following: "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 Wor 's Compensati aws of California." Signed ----------------------........ --• ------ :-_.: . ._Owner - By .................................... ....: af .... Title .rN. ........... ....... (if other tha owner) - -I a FCR-'DEPARTMENT.USE ONLY r✓ I APPLICATION ACCEPTED BY ... DATE 75/............... ------------------------------------------ __-•.......................................a..-...:r_..--•----------- .._ BUILDING PERMIT ISSUED - ------------------ ---•--....-•--•-...._.:.----_--------------------------- .._.:-..:._....DATE ...............--------..............--- ADDITIONALCOMMENTS ............... ........•---------••--••-----•........-..---......_............._.._........... •-------•-----------------•-----..-..-•----••--....----------- .. ............................. Final Inspection b -- -- .. �..... . P Y --•••-•......_.Date- .... .-- ................ ---------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E_ 1�_13 24i.'fsR Rav _5M 7172 3 M