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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - ---.....--�-•�-----_..-�- Permit No. `�1..�`..`�� , (Complete in Triplicate) This Permit Expires 1 Year From bate Issued Date Issued .. .......................,...........- Application is hereby made to the San Joaquin local Health District for a permit to construct and install the work herein k described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: JOB ADDRESSAOCATION .... .. -.� •'iZ'l � CENSUS TRACT ....... Owner's Name .............. ..... .... :....... Phone .. Address .......... ar- -- ---- .-, ......... A-x-- ------------ City Contractor's Name ........ icense #sJ7/..'� -. Phoney-r .�� i Installation will serve: Residence Apartment House❑ Commercial []Trailer.Court ❑ Motel ❑Other ------------------------ ---- / I Number of living units:.../... Number of bedrooms ---7l..Gorboge rinder--�~'. Lot Size. .......e C f•. •-•••-- Water Supply: Public System and name ...../O—Aou� ...... .....................f ...........................Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ i Hardpan ❑ Adobe jk" 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT j ] SEPTIC TANK ie- ---------- ----------------=--------------- quid Depth ....----.......-.. Li p Capacity .. Type ............... Material............. ........ No. Compartments ...................... Distance, to nearest: Well .. ..............----------------Foundation ........ Prop.Prop. Line ................ LEACHING LINE No. of Lines . --._ Length of each line..... _....... Total Length ... ..............-: E D' Box ?.c Type Filter Material .. ....Depth Filter Material -..../p.:'".`- Distance'to nearest: Well - -----..---. Foundation Cl. ......... Property Line ..-%'57 -- -•-•-----• SEEPAGE PIT Depth CZ477------ Diameter //?." ......-- Rock Filled Yes ' No (] . ... Number Water Table Depth r • --.�®..---•-.........................Rock Size .... ------ -: ....- - Distance to nearest: Well ..:. .(.�f� ----- Foundation -:- -�..--- •-• Prop. line ._a ---.•-...--•---•• �.. . REPAIR/ADDITION(Prev. Sanitation Permit# ----------- - - - ------------------------. Date ------------.-...-----------------1 Septic Tank (Specify Requirements) .. .. ...............................--- `... . ......-..��............_ ,.......` ................... Disposal Field (Specify Req ir`ements} ,,� . ::............ f� .00 ........ ' . ------ ---- . --------------- - ----------- ----------- ----------•--.... ...------- .........- ........ (Draw existing and required addition on reverse side) l�herefyeeertifyythat. I have prepared this application and that the work will be dopa in accordance with San Joaquin _ ..,. untyOrdinances, State Laws, 'and Rules and Regulations of the San Joaquin Local Health District. Home owner or can- Cosed 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 laws of California." Signed . -. �} ............ Owner ByTitle . .. ............................. if other than owner} I F R D MENT USE ONLY APPLICATION ACCEPTED BY . . . ..... DATE .... -.J..`... .. ..... ... ..... BUILDING PERMIT ISSUED ...... . •-- ........ ----------- .-- --....DATE _ . ...................................... r ADDITIONAL COMMENTS f .... ..... . • --------------------------------------- ........ ------... ........ ... ............. . . ......---- ......... . ------ ----- ...... _ - Date ...-` .- SAN JOAQUIN LOCAL HEALTH - - Final Inspection by: . ............ . --------- -- --.... I - 7172 3 u