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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ......... .......................... ....... (Complete in Triplicate) Permit No. ,7 ................................................ This Permit Expires 1 Year From Date Issued A//Date Issued _. Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is moder�i�n compliance with County Ordinance No. 544 and existing Rules and Regulations: '! JOB ADDRESS/LOCATION .._.. l...+7 ....... iVLY. -... QQ�L....................................CENSUS TRACT _..........._.... ...... I P, � �e 7 Owner's Name ............. .. ./............ .. -------------<--------------................ Phone ...�l� .J�.... � . _ n 1 Address ........................ .._..-----.... ----------- City .... Contractor's Name ........ ------------- .... -- . ......-----.License # ........................ Phone .............................. Installation will serve: Residence XAportment House❑ Commercial ❑Trailer Court ❑ Motel ❑ Other —....... ........•. ••--- ---------------- Number of living units:....c;2.,. Number of bedrooms ...__.Garbage Grinder _. Lot Size ..._ _'.-1^. -e.......... j Water Supply: Public System and name .--•_Ya /.2/f��---------- .........Private ❑ I Character of soil to a depth of 3 feet: Sand rJ Silt❑ Clay ❑ Peat❑ Sandy Loam E] Clay Loam ❑ I . Hardpan ❑ Adobe Fill Material _....._..... If yes, type _........... ....... .._.. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. lmust be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} f 1 PACKAGE: TREATMENT [ I SEPTIC TANK Size... Liquid Depth Capacity �pt��1xS Type &T&,I/ Materiai... 1No. Compartments .....1.). . . Distance to nearest: Well ----------- Foundation ...fQ.Q. �.... Prop. Line ...-S. . a LEACHING LINE K No. of Lines .. . _.._ ..... Length of each line ..... (� =....... Total Length .....-. .-. . 'D' Box y'_ Type Filter Material J'Vx� fear, epth Filter Material .....� .11C��_.-----.- -- I Distance to nearest: Well ..................... Founda}ion _- ..._. Property Line ................... SEEPAGE PIT [ ) Depth .. . . .......... Diameter _......_........ Number ........ .................._ Rock Filled Yes ❑ No : Water Table Depth --• --------_---------.Rock Size .......-•----------------------- � Distance to 'nearest: Well ...................._-- ----.-_Foundation .......... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ----------------------------------I SepticTank {Specify Requirements} .. •......._ -•.................................••------...-------------•--•-••---•-----•-•--------------------_-------------.... Disposal Field (Specify Requirements) ----------------------------------------- ........ ......................--......- -......... ......................... • I f - ....... .. ------. .......s------------ -------------------------- --------- ------------------.._...... ._.---------- ---- ------------------------- ....... (Draw 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 as to become subject to Workman's Compensation laws of California." Signed -- .............._ Owner BY ................. ................. Title . ... (If other than owned FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _......- ..........�d� G -•. - DATE .- ------------ ; BUILDING PERMIT ISSUED •. ......... ..... ... .. ----._.. :. ..._.........._....._._....... ...... ...._..DATE ....................................... .. ADDITIONALCOMMENTS ................:-- -----------------------------^----------------- ........................................... •__............. ................ ---- .... - ---•--- ----..... ----------------- - ............................--------- •- ------------------------------ ................ -- ... t ~� Final inspection by -.-- - .- ti _..-._ ...- ••------_Date _./ .1-�l ....__....._. + SAN JOAQUIN LOCAL HEALTH DISTRICT - e Li 13 24 1 ,&a a_., c&A 7 171 1 u