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FOR OFFICE USE:1 21 APPLICATION- FOR SANITATION PERMIT :"�. ................ ..................... Permit No. ..7 .:. � (Complete in Triplicate) ......................................................... i - . Date Issued .�L. .....73. ........................................................ This Permit Expires 1 Year From 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: J08 ADDRESS/LOCATION At _ '51. ......'...:....... ..........:...•-........CENSUS TRACT ...... .............. E terms l��,ffL .....Phone ... . . -Q ±�f......... Owner's Name .......__�...�-•-•-�.�..................lT.z......� ------•-••--------�-••----..__._..:.............._. .--. Address ----•-_.. . — . - • -•-- .......-... . ._ . CitY ? ... ... .. ........ .... g6o 7 I Contractor's Name _.....__ ry r �:�.._..... license # -`�r��, Phorte ._....... Installation will serve: Residence'f g Apartment House❑ Commercial ❑Trailer Court t❑ i Motel ❑Other ..................................... i Number of living units----- Number of bedrooms .::..::.....Garbage Grinder ............ .Lot.Size .4--5 .10 ........................ ' Water Supply: Public System and name -_101411 +--.-------.-•-..---.......................................•-----------_----__--..__...Private ❑ Character of soil to a depth of 3 feet: Sand D , Silt❑ Clay ❑ Peat❑ Sandy Loam fl Clay Loam D Hardpan ❑ Adobe.0 Fill Material ............ If yes, type ....................... (Plot plan, showing size of lot, location -ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: INo septic tank oryseepage pit permitted if public.sewer is available within 200 feet,) 6 PACKAGE TREATMENT ( } SEPTIC TANK f } Size............... ......... ............ ......... Liquid Depth .............I......... -.- Capacity ----• '::. Type :.......___.... Material.....--- No. Compartments ................. + n Distance to nearest: Well ...........Foundation ...................... Prop. tine •..................... F LEACHING LINE ( ] No. of Lines _._..__'..............I Length of each line-----_-.-----------.------ Total Length � 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ 1 � Distance to ,nearest: Well ........................ Foundation _.-------------------- Property Line ........................ I SEEPAGE PIT Depth -~Diameter Number Rock Filled Yes [j No ❑ ' Water Table Depth ...................Rock-Size r # Distance to nearest: Well --------------------- ..................Foundation .............__ .... Prop. Line ................... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. I ................. Septic Tank (Specify Requirements)....=------•--•-------------•--_-------- ------------- • ---•-•---•-•...........---•-••...--•--•. ...........__..........-------- s LI_ Disposal Field (Specify Requirements) --:-----3 ---x. i ----- . f..!_ _.-_._."T ?_...N`?��.. .'_" ............... ------------------------•---------------•---•-------------- �-� -----------------------------......_..--------•---•--•-•----------•--------- ---•--.....-••-•-........---- -_...._--------------•----------------------. --------------------......._...-.•------------------------------------..................-••-•.................. ......... (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 iicen- 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." f > r Signed . .. . ------------------ Owner By ...... --------------- Title -•---•--..._..---..----... --------- ...................................... (If other than owner) i OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...'. '. ,, ................ ................................................. DATE .... — - .............. BUILDING PERMIT ISSUED ......... ....... DATE -------------•----._....------------------. ADDITIONALCOMMENTS ....... . ./. .......... . ........ .................................... --- --- ..............................................: ..--------.._.._ .........................•------___......... ......._.. .._. .---- -----------------•--•---------------...----------------------------------- ............ ---•--••--------- ------------------_ _........_........----•- . •-•---......-••-•--•--•--•••-....... ......------....---•--•-••------...._..----••---......_........--------.._... .......... -•---•------•-•--------- ....... ...... . • ..................................----........-......................._.................... . Final Inspection by: . ---- •----...--•..:..................•--•--•---•---....................---.Date .... _7 ..3-.: 1 SA JOAQUIN LOCAL HEALTH DISTRICT E• H.L3 241-'68 Rev. 5M _ 7/72314