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FOR OFFICE USE. -- ........ r'1111CATION FOR SANITATION PERn (�( ....................................... (Complete in Triplicate) Permit No. .. This Permit Expires 1 Year From Date Issued Date Issued ..0 :_ P 7� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work scribed. This application is made in compliance zwith County Ordinance No. 549 and existing Rules and Regulationsrein �e JOB ADDRESS/LOCAT . � .. .. __... .. .. "._, _.t ............CENSUS T RACT e: ... . . ... ..........:....•-.........------....:Owner's Name _.. ...'....P one ................f ............ City ... . ............................................... Address ........Contractor's Name .... ..... ......License # Phone ..................................� f Installation will serve: • residence 0 Apartment House 0 Commercial QTroller Court 0 Motel 0 Other _.'?11-.4X Number of living units------•,?�..._ Number of bedrooms :_„.....Garbage Grinder . ......... Lot Size --- :�:..---•-_.- Water Supply: Public System and name ...I................ --__.Private Character of soil to a depth of 3 feet: Sand 0 Sift E] 'Clay C] Peat 0 Sandy Loam Clay Loam Hardpan❑ Adobe 0 Fill Material ..... If yes,type ........................ l [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 pi p seepage a e t ermitted if public sewer is available within 200 feet,J PACKAGE TREATMENT [ ] SEPTIC TANKt size.... ...............................................- Liquid Depth .............. l Capacity •------------------- Type .................... Material--...... No. Compartments Distance to nearest: Well .....................................Foundation ...................... Prop. Line LEACHING LINT: 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 [� ... ..... Water.Table Depth. ................................................Rock Size Distance to nearest: Well ........................................Foundation --__- Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date Septic Tank (Specify Requirements) .... ---------- --•-- ; --....-- •--•----...... -••••- ...... --------------------•-------------. --._-.-•-- Disposal Field (Specify Requirements) -- :� � k fi 47... . -- . .. --------------------•-••--•------ --._...._..-----•-----------------....••-• _...... (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 !teen- 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." Signed ........... ............. •.. Owner I .. by ..... ................................CZ '-- = --.. 3itle .. r._.. ... (If other than owner) I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. _. .....__...... DATE ... -x •-- B ILDING PERMIT ISSUED ................. ...DATE ADDITIONAL COMMENTS -•---..._..•--- .......................................... ..... Final Inspection 6y: .....:....................•----- f ---•----- ----- ..... ..........................•--.....Date F ..... SAN JOAQUIN LOCAL HEALTH DISTRICT -Y 111 u