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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7 _ ��o ........... .............. •-••--...... ._. _...... Permit No. (Complete in Triplicate) v.. ... This Permit Expires ] Year From Date Issued Date !saved". ... 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: n JOB ADDRESS/LOCAT N .... _ .�r ..._.._/✓f..._,.1 +,. .. ......................CENSUS TRACT .......................... t Owner's Name �- �rz..� ..................................... � � one . ...�1 Address . . .��...�.�....... �- �` .... Ciry .. ., P�.z..------------- -,.........---..... Contractor's Name -- 11-5 _ ....... ..:... ....License ��y .. Phone s- ` Installation will serve: Residence 0Apart nt Hous Commercial❑Trailer Court C Motel ❑Other , Number of living units:__...:_...__ Number of bedrooms Garbage Grinder ..._........ Lot Size ..'.... ...... r� . Water Supply: Public System and name ..Private ❑..- Character of soil to.a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom [B--,-C—Iay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ............ It yes,type (Plot plant, 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 permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT I ] ,, SEPTIC TANK( ] Si e....s: ,X__,CP, --r --�........... Liquid. Depth 5 ��......... Capacity ___. Type _ Material -No. Compartments .::.......r . Distance to nearest: Well ....................................Foundation ...................... Prop. line .... fLEACHING LINE [ ] No. of Lines _ is2l__ Length of each line......I.. C............... Total Length .... ©' BOX Type filter Material ....................Depth Filter Material .........................:.................. � Distance to nearest: Well ........................ Foundation ........................ Property Line ....................... . 4 SEEPAGE PIT ( ] Depth -------------------- Diameter ------- Number --------------.............. Rock Filled Yes ❑ No 0 ' Water Table Depth ----------------------••- ----....------....Rock Size .................................. Distance to nearest: Well .........................................Foundation ........ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit alE ------------- ------ .......... Date _..._.._.._........._....:,.:.....) SepticTank (Specify Requirements) --------------------------•------------------------------------.-._.........--- •-----..----•---------------..-------------------•------------ DisposalField (Specify Requirementsi .-•------.........-...............................---------------------------------------------- ' ............................... + --•----------------• --------- --------------------- -----------------------------------------------.. ........................................:........................ ------------------------------------------------------- -----------------•--------- ...._........._......._.......................................................................... (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:blstrlct. Hoene owner or licen-sed 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 Workman's Compensation laws of California." Signed _.... '= ------------------------- Owner BY �. �� ................... --- ...------- lit#e .--- -- ..� Ilf other than owner! .-- •- �� - -• .-•-- .......... FO DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY - ••-- • DATE .,,: '_ -....-...:. i BUILDING PERMIT ISSUED -:'.- ---. :. ......................DATE ........................................... ADDITIONAL COMMENTS -------------------.------------------ -------------- ------------------------------------- -.--------------------- ---------------------------------------------------------•------------------------------------ .---.._....----------...._.__.....------------. -' ------- --------------- ... -------------- Inspection by: ----------- -- ----------------- •-------•--------•----- ------------------Date . yQ ..- ..... ..-. . ....... ...... EI 13 24 1-68 Rev. 5m SAN JOAQUIN L L HEALTH DISTRICT 8/7h 3M