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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _......._,_. ,............................... Permit No. ..7�7..... - ;> • (Complete in Triplicate) ............................................---------... Date Issued ..1�.'/3"•� This Permit Expires 1 Year From Date Issued 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 3n.compliance with Countyi Ordinance Ngo. 55449 and existing Rules and Regulations- -5k egulations: JOB ADDRESS%LOC �..?�.��. .�- --• -•- '- CENSUS TRACT ... Owner's Name ....._. � ....... --- •.....--- ......Phone .................................... ......... .... . Address ...... - ... F - C'tY .. Contractor's Name .. .......... . r - -•�.- t--,.License # _ � ..fir-phone ............--..-............. Installation will serve: Residence Apartment House C❑ Commercial ❑Trailer Court 0 Motel ❑Other ----------------------------- ----- Number of living units:.... Number of bedrooms -..-3---Garbage Grinder ...-_....- _ Lot Size .......- -.......................... Water Supply: Public System and name ...................... ..............................•-.•--------------..•...----••.__...Private \ Character of soil to a depth of 3 feet: Sand 0 Silt C3Clay ElPeat❑ Sandy Loam Clay Loom C] Hardpan ❑ Adobe ❑, Fill Material ............. If yes,type ........... ---------------- (Plot lan, showing size of lot,rlocotion 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 I ] Size----------- .............................._. Liquid Depth ......................... Capacity .. . ..... ...... Type ------------ ------ Material..--........ ....._.. No. Compartments ...................... .._.... _Foundation ---------------------- Prop. Line Distance' to nearest: Well - ._ ..---....-----.••- . ........:... � LEACHING LINE [ ] Na. of Lines .. ... _.,- -- Length. of each line..... Total Length .......:..... .. •----..:.. S 'D' Box ..--.-. Type Filter Material .....____•-••-------Depth Filter Material .---------------------------- Distance ._.._.___....:............Distance to nearest: Well ------------------------ foundation .........-_.-------_..- Property Line -----•----•-•-- SEEPAGE PIT [ } Depth . ...... ......... Diameter --------------._ Number ......... ------ Rock Filled Yes ❑ Water TTable Depth -------- -------Rock Size ----- --------------- Dista nce •--Distance to nearest: Well ----------------------------------------Foundation ................... Prop. Line .............. REPAIR/ADDITION{Prev. Sanitation Permit# -------- -..--------------- •------- Date -------.-------_._...---------- ------------ --.) Septic Tank (Specify Requirements) -.-- .. ` Qposa Field (Specify Requirements) �f"'�� ----- ---- �-�� --�� - - . - 400 a , i2 ....._ . { raw existing and required additi n on r verse 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 Ilcon- 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 f as to become subject to W r an's Compensation laws of California." Signed _:.. - . .. .--- _ ._p.�.,_ " 1----- ----- ---- Owner .. . .. ........ .......... -/ ---• "- - .-"...`.. . -Title . .... .. ..._. C�16'l. -.....-.._. ..-..._._...........__..-._. By If other than owner) FOR DEPARTMENT USE ONLY -- ----- - ... -•-----• APPLICATION ACCEPTED BY ......... ....... . .............. ............... DATE ...-.... BUILDING PERMIT ISSUED -----..._ .- .............. . . DATE -.----• -•---...---...-- -•--..._..._...._. i ADDITIONAL COMMENTS ...¢ _ .. _ ._D .._.... .�. ... ... t- .-•------ ---- .- _-- . . . I -----------I-----------I--- ------ ....---- -------- ------ ....__...-------•-..... Final Inspection by: ..-•--, ..... Date .......1�'.-.Ll7-?/... SAN JOAQUIN LOCAL HEALTH DISTRICT 7./72 u 13 24 1_'f.A Rav SM