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s FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .........2..r�-:?`.x��,::.c�....1..1.... (Complete in Triplicate) Permit Na.7 _77.2.... .........................._..................... ......................................................... This Permit Expires t Year From Date lssssed Date Issued .! _=-7 6. 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 compliant with County rdinance No. 5.49 and existing Rules and Regulations: JOB ADDRESS/LOCATI .... �...................................... CENSUS TRACT Owner's Name ........ _ ........................ ----------- ..:......AAAA-----Phonef �,' Address ----------------- `..... ....City ._.. ... ... �? •----- ---------------------------- Contractor's -•--------- Contractor's Flame �Q,_-- ................ �+ License � Phan. � l% _..- -•--Q �-- •..................... ..=AAAA--:--•--•-••--- -----AAAA-- Installation Will serve: Residence Apartment House f] Commercial E]Trailer Court jj rr Motel ❑Other..............-.............................. Number of living units:.....I-..... Number of bedrooms .-- .:_Garbage Grinder ............ Lot Size --------------- Water Supply: Public System and name .- Private trio Character of soil to a depth of 3 feet: Sand b Silt[] Clay ❑ Peat 0 Sandy Loden.❑ Clay Loam❑ Hardpan p Adobe 0 Fill Materlal ............ If yes,type............... ...... ...... (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 permitted if public s9wor is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK ` Size... ............. ............................. Liquid Depth Capacity .... Material...................... No. Compartments � ---...___...AAAA YID ................ ----•AAAA--•--AAAA.. Distance to nearest: Well .............AAAA........_._.....---Foundation ...................... Prop. Line....................... . LEACHING LINE ] No. of Lines Length -of each line................ .. Tota! Length ----- ........................... 'D' Box ........._.. Type Filter Material ....................Depth Filter Material ....................................... Distance to nearest: Well ----------------------- Foundation ........................ Property Line ........................ - SEEPAGE PIT Diameter ............... N [ ] Depth .-•AAAA-___--- -- umber .AAAA---•_...... ..... Rock Filled Yes ❑ No +] E Water Table Depth ................................................Rock Size ................... ............ Distance to nearest: Well ........................................Foundation .................. Prop. Line --------------.------- REPAIR/ADDITION{Prey. Sanitation Permit# ............................................ Dote ...._......______...:_ ............ SepticTank (Specify Requirements). _._:......-- -----.....................................................................................................AAAA-•-••-•----- Disposal Field Requirements)fy-(SpeciReqts[ .... _. � - - ------------AAAA-- -. --- •--- .............................. ...................... _ ................ ---- -- _AAAA... . ._ -----------------------AAAA-- - -•---�3 �r � r ----AAAA-- ---AAAA-• ----....-- .... -- bC ..._��._... - --- •... .. ... . (Draw exist' g and equired Addition on reverse del I hereby certify that I have prepared this application and that the work will be dare In accordance wins San Joagssla County Ordinances, State Laws, and Rules and Regulations of the 'San Joaquin Local Health:District. Hance owner or licen- sed agents :signature certifies the following: g "I certify that in the P mance of the work for'which this permit is issued, I shall not employ any person in such manner as to becom subil ct t W rkman's Comports tion law of California." Signed :. ! --_ ..- - U - ..... OwnerLY By ..._.__..- y - -------- •-----9�-,� Title _. .. .. .............._......... { (if other than owner) FOR DEPARTMENT USE O APPLICATION ACCEPTED BY _._... . ...... . ...... ---•------------•-------------- ------------------------- BATE ---..--/_ .�� . .--- ---•-••- BUILDING PERMIT ISSUED .._--------- ---Z--..DATE :..:.............. .--- ADDITIONAL COMMENTS AAAA. . ---------------------------- -•AAAA.AAAA-- :....._ ---------------•-----•-----•-------• ------------.._...._.__.....-------- --------- _._._......... .............. ................... . .. .. ....... ............................ . Final Inspection by- ------------------- ` � --____--..Date -.--- . .. '..� : > 13 2}� 1-b13 2 v. 5�i SAN JOAQUIN LOCAL HEALTH DISTRICt 8�7h 3M