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FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMIT .....................................1•-....._ _ (Complete in Triplicate) Permit No. 2.............. .. ......................... _._._�_.. �. ............_ _. This Permit Expires 1 Year from Date Issued Dote Issued ...s... .�� Application is hereby made to the San Joaquin Local Health District for a permit to construe► and Install the work herein described. This application is made in compliance with County Ordinance No. 549 and ex ting Rules and Regulations: i ro- 7© JOB ADDRESS/LOC AT N ...v ._...._... '!? �,s �;.. . ............CEN S TRACT ...... 1 r yrJ • -• SU Owner's Name ... .. .. .._. ..... ...... ........ ....... .......................................................: ........... ......... ................... r Address . . ....... �-��...... .-._. - '..:.. City _... .,..-... .... ._. Contractor's Name _.... _/ .. ........... ..............License Phone ...... ........... ......... Installation will. serve: Residence Apartment House Commercial{]Traller Court (] Motel ❑Other ................................ Number of living units:... .... Number of bedrooms ._, ....Garbage Grinder ............ Lot Size Water Supply: Public System and name .............. . --•---•• -... ......._.............................................:......Private Q Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam.❑ Gay loam ❑ Hardpan p Adobe 0 Fill Material ..:......... if yes,type............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) `C NEW INSTALLATION: (No septic tank or see age pit .permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Size-,— �.'.�._.x-5 .................. Liquid. Depth 1�................... . Capacity lr Qo-.------- Typep-Z_ew. _ Material--...9tr-� No. Compartments ............... Distance to nearest: Well ...........&_Z2...............Foundation ...../f>---._......Prop. Line ...... +l LEACHING LINE [, No. of Lines .......3------------- Length -of each line.........�`'.�'.�.. Total Length .... 'D' Box Type filter Material Is.k....Depth Filter Material .......11. tf. Distance to nearest; Well ......J.'on--f...... Foundation .....i-P..K.:.... Property Line ......./.Q.......... SEEPAGE PIT [ ) Depth .----_--__-- ... Diameter ---------------- Number ............................. Rock Filled Yes [] No C Water Table Depth ................................................!tock Size ............-................... . i Distance to nearest: Well ..._...•................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION IPrev. Sanitation Permit# ...............__._--........................... Date --.--......._............_..........) I Septic Tank (Specify Requirements)....---- -----.....--•---------------- ................. ....... ... ....... Disposal Field (Specify Requirements) ---------• ........_------------ ------------------------------------------------------------ .................. -----------------------........._..---------._....----- -- •-----......._. ............... (Draw existing and required addition on reverse side) I .hereby certify that 1.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: 1 "I certify that in the performan of the work for which this permit Is Issued, I shall not employ any person.in such manner as.to become subject to Wor a 's Compensation laws of California." Signed -•----------- •----------- ------- ..... Owner _7__ TBY -• �__E--- ---•--- • itle . . .......... ................. (If other than owners FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..---.. _.___-• -----------711.1- •------------ - DATE .... ?:. .:., 7: .• BUILDING PERMIT ISSUED --•-----------•_ ............. ---.. _:.._._ ...._. ._.-------7111 DATE - .......... .............. ......... -- - ADDITIONAL COMMENTS ........................................1111 ---------------------------------------------------------------------------------------------- -.......................------. -------------------------------------- Final Inspection by: y� �/�/ _ _:.r .....---------•-•........ ......•. Date - --- -- - -----•-- ---•---------------•-•--•---•--------...........--..__.._.._......_ . EH 13 24 1768 liev. l SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M f