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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Complete in Triplicate) Permit No. .7 .� y This Permit Expires 1 Year From Date Issued Date Issued IgA1:?.-3.. 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/LOCATION y1V ... . .. r""L .... CENSUS TRACT ...T. ............ � .Owe`s•,,Name - .. ..... Q ...... ..... Phone ...... ......... ................ Address 4 .......... . City ..................... Contractor's Name • 7a-A, .... License #ILMSY�l . Phone ...... . .......... ......... Installation will serve: Residence;<4partment Housefl Commercial ❑Trailer Court 0 Motel ❑ Other .... ... .. .......... ........ Number of living units: Number of bedrooms ....... ...Garbage Grinder . .. .... Lot Size .. ....... ............................ Water Supply: Public System and name .......... ........ ..... ...... . ..... ... . ....... . ........... ........ ..........Private 1`71 Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam C] Hardpan ❑ Adobe ❑ 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 [ 1 SEPTIC TANK[ J Size .... .......... ....... ........ ... Liquid Depth .. ...................... Capacity .. ........ Type ... Material.. . .... No. Compartments Distance to nearest: Well r ....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 ....... perty Line ......... Pro .......... ............. SEEPAGE PIT i J Depth .... ......... Diameter ........ Number Rock Filled Yes ❑ No C Water Table Depth .... !{ .Rock Size ...... Q Distance to nearest. Well .. ......�.° .....,.Foundation ....... . . ..... Prop. Line .............. REPAIR:/ADDITION(Prev. Sanitation Permit# .. ..... .f Date ..................................1 ; Septic lank (Specify Requirements) .. .. . .......... . ...... ... ......... ,y /tea. ; -.. .. Disposal Field (Specify Requirements) ........ `rw r .....- —... . . ........� r (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that tllie work will be dome in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of we San Joaquin Local Health District. Home owner or Hcen- sed agents signature certifies the following: t "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .......... ..... ....... ;............. ........... Owner ....,. Title ...... . ........ ..... 11f other than owner) R DEPARTMENT USE ONLY _ APPLICATION ACCEPTED"BY ... - I �- ^— DATE .:.. `( 'l .... . ....... BUILDING PERMIT-ISSUED ....... .... ... .....DATE ... ...... ......... ....... ADDITIONAL COMMENTS .. ...... ............. ...... ... .. . .. ....... .......... . ...... ....... ..... . .... ....... . . ............ �. ............ ...... ......... ................. � , �� ... . ....... .. ....... ........ ........ ....... Final Inspection by: . �,-QY,� .. ........ Date SAN JOAQUIN LOCAL HEALTH DISTRICT F H O 1.'AA RPv. 5M