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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............................I........ •----------• Permit No. ...7i%.:.3� . ...... ....' (Complete in Triplicate) 4.. ................ Date Issued This Permit Expires 1 Year From Date Issued i 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: JOB ADDRESS/LOCAT N ..L �o---4r .. ...•--- fr ... CENSUS TRAC' -- .. Owner's Name ...... .... --- -• -- ...:............:............ Phone ..._._.. a .... . ........:....... .---------- - Address --....--- _..'...L�`' .._....1.. .® .... ..........:0. --r .............. ,f Contractor's Name ........License # -.W.59Z Phone ......:....................... Installation will serve: Residence❑Apartment House0 Commercial❑Traller Court 0 Motel ❑Other .... Number of living Units-_...... ... Number of bedrooms ............Garbage Grinder ............ Lot Size ............................................. l Water Supply: Public System and name ............... .... ....................................Private ❑�' E Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam {] Clay Loam ❑ Hardpan ❑ Adobe 0 Fill Materlal ............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,[ i PACKAGE TREATMENT [ } SEPTIC TA14K f ] Size...................:............................ Liquid Depth .................... CapacityType --- 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 0 Water Table Depth ---------------------------- --------------------Rock Size ................................ Distance to nearest: Well ........................................foundation ---------........... Prop. Line ------ ....••......... REPAIR/ADDITION 1Prev. Sanitation Permit# ......................................... Date ...........................-.------1 C.X* Septic Tank (Specify .Requirements) ---- ----•------ ---------------------------------------------------------w........................................................ fir/ . Disposal Field (Specify Requirementsl ---- _... - . _ « _._.. -- ------ - -------- ............................I------ I •---------•-•--•-----•--•----------•-•---•-•---•---------•--------•-- ------ --------- -----------•------..----- -..................................................... € (Draw existing and required addition on.reverse side) I hereby certify that 1 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'Leccil Health,District. Horne owner or. Own- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit Is Issued, I shalt .not employ any person in such manner as to become subject to Workman's Compensation laves of California." Signed -------------•----------------------------------- Owner _ -Title :.. .................. BY ---•------- ---------•- .. . ............. ............ (if other than owner) FOR QEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ----------- ------------------------------ DATE ------ BUILDING PERMIT ISSUED ..... .... ......• DAT!` ---•-•----- ----•---•-- ADDITIONALCOMMENTS ...................................... ................•--------.............. _...-------•----------------....------........ ............................... r. .___. --------------------------J`�.................... _•-------- --- __.................--••••-•-••-•---•--------------•--•.....--------------------------------_-- _..__.. _..•.•. ___...... .._ ..... ..--- .-. _. _ final Inspection b ------------------------------------------------------Date . .. - Ell 13 .24 1-68 Rev. 5t SAN JOAQUIN. LOCAL HEALTH DISTRICT 8/7h 3M