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' FOR OFFICE-USE. : APPLICATION FOR SANITATION PERMIT y �....--- •... .......... . J (Complete in Triplicate) Permit No. .. This Expires Issued _.._..�--_.................. . Permit 1 Year From Do Date Issued .�5:7.�:.7• 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 complian a with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA ION ... r ... C.rt4 ......CENSUS TRACT Owner's Name ...... .......................... ....................... ...... .......... Address Phone /. .. ....City .. , may. ... Contradar's Name cen h �-• "._ �-'-...... ... . f.. aB .......... ....P on Installation will serve: Residenceo Apartment House Commercial oTrailer Court iMotel Q Other INumber of living units: Number of bedrooms Garbage Grinder ---•--- g ..._ tot Size- Water Supply: Public System anal 'home ......Private - ----- ......... ..................... Character of soil to o depth of 3 feet: Sand L7 Silt-0 Clay O Peat❑ Sandy Loam o Clay Loam Vr{ Hardpan-0 AdobeE[ 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 } SEPTIC TANK t � Size. X'-.e�.. - Liquid Depth ...................... Capacity / � a — •-----------•• --- YP ---- ---�--'� Materlal_�- � No. Compartments 2— Distance to•ne est: Well ...................Foundation �O Prop. Line ..A..._-- . f .......----. LEACHING LINE (]" No. of Lines - -----------------=------- Length of each line---: .- Total length ---•---/;- .7 . �. i pri D' Box .._.._..._. Type Filter Materia -�_-_Depth .Filter Material /00l .. _ s........ Distance to nearest: Well K p.`.............. Foundation .._ .-..�..�..- property Line . SEEPAGE PIT Depth _�' -�.. Diameter � Number Rock F#I ed Yes No i(] - --.--.�� s�.-•------- ._.. . �t r' Water Table Depth ..---f -.•-`�-----____-- -•----.Rock Size ... .._- . �r Distance to nearest: Well ...�_ __ - Foundation .._... _- Prop. Line ...�'..... ••-----• .._...... REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------------ Date ------------_........... } Septic Tank {Specify Requirements) ................... ..--•-•-----------------------•--•--........._•---._......._ ..I........._.--------• Disposal Field (Specify Requirements) ..:.:............: --------- .......-......................................................................... ------------------------------------------------- ------•• -----------•--•-------------•------------------•---•-•------- ........................................ raw 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 Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local H@alth:District. Horne owner or licen- sed agents signature certifies the following: "I certify that in the performance of the worts for which this permit is Issued, 1 shall not employ any person in such manner as to beco a subject Workman's Com nsation la :o�_.f— California." Signed --- •.-� f Owr er_- - ----- ----------- By ---------- ------- -------------------------- --- Title _.. ._ (If other than owner) - - ---- - -- - - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _.._. . -•----------- - BUILDING PERMIT ISSUED _...-_-_-• ©ATE :...._._. ._�. ... �--=-...-------- . DATE _... -----••. •--_..._ ADDITIONAL COMMENTS ------------ - .---7 .-,. -_....._..----._._...._ t/ ................. -- --------•-•----------••------------------------------------------------------------- ----- ------- _... Final Inspection by: _.... - _..-..---- -------------•-----............------------------ -------Date ....5 /1.- —7 ........ ----- EH 13 2a 1-6 v• SAN JOAQUIN LOCAL HEALTH DISTRICT _ $/7h 3M Qp- ----