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FOR OFFICE USE: (AIPLICATION FOR SANITATION PERI .... .. .- ....................... (Complete in Triplicate) Permit No. ..... . ------------------..._ This Permit Expires 1 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 herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: J013 ADDRESSJLOCATI N G'---_- .._. . __._.,1.C'? Q.-..1L. .......................CENSUS. TRACT .........__....._._._..... Owner's Name � ?L- �Q�•:Q�_________-__ ................ .......................:....... .............Phone ..._.....__.....__._............••--- Address .... -+ ---_--__.- .._...__ City Al-.......................................... Contractor's Nome .._._. :. . --••--- -- _-.._ :..Licen1.��.� se # V Phone .............................. Installation will serve: Residence partment House❑ Commercial ❑Trailer Court 0 Motel ❑Other .................:.......................... Number of living units:...--/.___ Number of bedrooms 3......Garbage Grinder ............ Lot Size .. - ...... Water Supply: Public System and name ................... -••---------- ........................................ L7" Character of soil to a depth of 3 feet: Sand'[,] ilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ 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 ] SEPTIC TANK{ Size...............................................1. Liquid Depth __.._-,_--................ Capacity -------------------- Type -,:. .......... Material...................... No. Compartments Distance to nearest: Well Foundation ...................... Prop. Line ----- LEACHING LINE ( ] No. of Lines ........................ Length of each line-------------- ...... Total Length Type _..___-Depth Filter Materiel ____________ _____________ ... D' Box ...._..---- T e Filter Material ______-__: ,---•- ....... Property to nearest: Well _.. foundation __________ Li ne ..:..:. Z SEEPAGE PIT [ ] Depth .................. Diameter ---- ........... Number ------ ..................... Rock,Filled Yes ❑- No.0 Water Table Depth .......................-.........Rock Size --------•..._ ............ ....... Distance to nearest:.Well .................. . ______Foundation --------------_1 Prop. line ....................... AAC REPAIR/ADDITION(Prev. Sanitation Permit# ...._____................................... Date -•-----_-_----....___---__-_------� SepticTank {Specify Requirements) ............ ............. ................... ....................... ------•-•---------- ---------................. Disposal Field (S ed v Rfequire nts) .._.. - �� _ : ..--__ `- -------- ----- - --•- --- � ._ ________..........._------------------------------------------------------______________w_---------------------------------------------------------------- ._......._.....___/_.___...___ (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 �b County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Nome owner or liters- 006-- 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 s ct to Workman's Compensation laws of California." Signed .......... - __ Owner By ___... ...... .....(Ri;t;� . Title .. ------ other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .---------- _! ---------------.............. .......................- ........... DATE ....__.7__`e_ BUILDING PERMIT ISSUED ----------------- ------------ ----------------------„__- :..:...-................... DATE _.._..: ADDITIONALCOMMENTS --------------------------•-----..............._..---------------------------- --------•_......................_.... :.._.... ... -------------------------------------------•-_..-...---------...:--:-•---•---•----••--_._....----••..------.._...................................---•-•••-------.:•----•--- ----------------------------- ------------------------------------ ......4....... A ............................. .......... Final Inspection by: `' ..........................:................... ..:..:............• - ----------- ..-- --.Date .__._-------�--------------- ._ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.3.3 24 1-'68 Rev, 5M 7177. 3 M