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MM vrrK.0 uecAPPLICATION FOR SANITATION PERMIT ....................................................... (Complete In Trip!lcah) Permit No. .�..... .: .� ...................... I............................... This Permit Expires t Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work heroin described. This application is made in compliance with County Ordinancje� No. 549 and existing Rules and Regulations JOB ADDRESS/LOCATIO 1.-o..�.-o.�--.. .:..: ...........................CENSUS TRACT ... ..... ....... Owner's Name ............................................................................Phone .V7&n V-0 r�..?...._._ ..... ... .. ... .. Address ..........._k7 .� - - ------------ X .............. .......I...............City .. ..................... Contractor's Name �f1..................................... W ._...License # B... Phone . :.f..7.._.... Installation will serve, Residence Apartment House C) Commercial ❑Trailer Court ❑ I Motel[I Other............................................ Number of living units......1_.... Number of bedrooms --- .....Garbage Grinder ............ Lot Size l.Q... ............:� Water Supply:_Public System and name ..................................._......-•---.......__._..._................._..................------------Prlvatex Q '`Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam C) day Loam ❑ Hardpan❑ Adobe W call 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 TANKze.....�r. .�,?�..L �... ... Liquid Depth V y.............72— � T " Capacity Typo . -.. Material. .:. No. Compartments ..... ... Distance to nearest: Well' ..:,t'_ Q ....._.Foundation -.10.............. Prop. Line r LEACHING LINE No. of Lines �.... v.......... Length of ea... line.... ............ Total Length .....Z70......... 'D' Box ---•--------- Type Filter Materlgt�.P'.....Depth Filter Material ..........1.EI. ..................... • , Distance to nearest: Well .:. . .%. .� .... Foundation ......�O. `'...... Property line `......... SEEPAGE PIT { j Depth ..... ........ Diameter's: X......... Number .............y...... k Filled Yes No DjAn,, CuA.,Ts Water Table Depth .......................... ....................Rock Size _-. .�� ...... Distance to nearest: WellfBD........................Foundation ..... .... Prop, line ...� ........... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................I SepticTank (Specify Requirements) ......................................... ............................................................_............. ..... Disposal Field iSpecify Requirements) .................................................................................................-................................... ............................................................................................................_......................................................................... •................. (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 Local Health District. Homo 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.iaws of California." Signed ------- qi -------------•--------- --- ........ ............._---------....... ........ Owner By ............ .. .. ...... �r�..................................... Title .... -f............... ......... ........... ath t an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPT D BY ......... ... "^--••.................................................. DATE ... :. ......:-: BUILDING PERMIT ISSUED .....................:...... ...............DATE -....... ................................ ADDITIONAL COMMENTS .................................................................... ...................... ... ............................... -..-. ... ........................•---................... .............................. D Final Inspection by: ................................ ate ...: ........ ...a.`)r L�1. ...... IEi 13 2h 1-68 Rev. 5N AN JOAQUIN LOCAL HEALTH DISTRICT 874 3M