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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' {Complete in Triplicate) Permit No. -:.....3....... , ). ,...... ......................I----------------- This Permit Expires 1 Year From Date Issued Date Issued .l� 9.�. 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: f i JOB ADDRESS%LOCA ION ._...1.. __ __/_ ....... t..•. wC9 .. .V._J CENSUS TRACT --•--.................. ' Owner's Name L _ - U 5 --- f __ CitS'Cf} ©/u 4} I Contractor's Name . 44 .--- -. } . -_--- APC . .....License . �.�I _ Phone - --�e/f. 7 / Installation will serve: Residence [Apartment House❑ Commercial ❑Troller Court ❑ Motel ❑Other ..................... . _ Number of living units:-.J....... Number of bedrooms ..._-Garbage Grinder - 00 Lot Size .. ... Water Supply: Public System and name .....-:......-................. ---•. - Private Cl [� Character of soil to a depth of 3 feet . Sand I ❑ . Silt❑ Ciay,❑�_�Peat C7�Sa dy Loam ❑, Cia Loam- Hardpan /Adobe ❑ Fill Material ...... •.... If yes, type .....__... � (Plot pian, 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 f ] SEPTIC TANKSize-..--.-,,-, - . Liquid Depth . ..'� � ] ------------- �------..._ _. -- ......... .............. f H capacity .. Type -------- ----------- Material. ... . ...... No. Compartments . Distance to) nearest: Well Foundation ...................... Prop. Line .---•-._••----•._.....,� LEACHING LINE ] No. of Lines Length of each line ....:.... ........... .... Total Length ............................ 'D' Box ..._ ... Type Filter Material ____________________Depth Filter Material Distance to nearest: Well -------- Foundation ............ Property Line SEEPAGE PIT ( ] Depth - . .- . --- --- Diameter Number . ...... .........__...... Rock Filled Yes ❑ No Water Table Depths 4 -•-------_----------•---Rock Size .....-- - Distance to nearest: Well ---------------------------•------------Foundation -----.....-- ....... Prop. line .................. REPAIR/ADDITION(Prev. Sanitation Permit# --.----- --------. --------------- Date ........................ ----_--� . t Septic Tank (Specify Requirements) ........................... . - ..................................•...................... .......... -- Dispnsal Field (Specify Requirements) --- ...._._. ----.....-- -----7 r_ .n fQ.. . _��. P/ (Drciw 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 District, Home owner or licen- sed 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 G as to b:9er . ct. o rkma ` ompensation sof California." { Signed ----- Owner By .._: � .. ... .. ------... Title . ... . .._than owner) S FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. yDATE'.....--c - ..---- ....-..----.._._---------------------- ---- --••_...BUILDING PERMIT fSSUED .. . - -----�---..... . ....._....._DATE . . _........ . 1 . ... ....... ................--....._ ADDITIONAL-COMMENTS . ........... . - - -•-----._....'-........... .. 1 - . .................... .........I........ Final Inspection b ----- .-------------------------- ----- --- ••---- --•-----...................---- --- -•-----....... PY -----•------ •-----••-•-------------------------- - -----•- --..._-Date ..-- r �}..... ............... SAN JOAQUIN LOCAL HEALTH DISTRICT , 4 E. H.13 241-'68 Rev- SM .�,'