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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .... _..._. __. __ Permit No. . . ......."....- .." (Complete in Triplicate) This Permit Expires 1 Year From Dote Issued Date Issued .77/ ..7 •. ........................ ...._----.,. . ...._--_ 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: .. -: ':•/v. %s '�. c ... CENSUS TRACT ...... ................... JOB ADDRESS/LOCATION �. �: -. •�-.-.",--". Owner's Name .. ..-.�.......(.�.c�X-r K.rr' ...... _. . ............. ...... ....."Phone ........... .........".-..."......". Address � ............ ."......City .." .... . ....""...".--....... ► Contractor's Name fut� 4{'iv .". Phone . .-.. .. ."............."... Installation will serve: Reside hce Apartment House❑ Commercial IJTrailer Court ❑ Motel ❑Other ... .. ....... ............ .... Number of living units: . / Number of bedrooms ._.S. ....Garbage Grinder Lot Si-e —.. -"..................""..........""".. Water Supply: Public System and name ... . . ....... ... ..... _...... .... . .... . ......... .... ........................ ....._. ....__.Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Ciay 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.) �A NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available.within 200 feet,) ��) PACKAGE TREATMENT [ ) SEPTIC TANK[ ) Size ....................... _-- - _. Liquid Depth ................... ...... O Capacity - Type ...... . - .. .. Material. .. . . _. No. Compartments . .................... Distance to nearest: Well _ . .. .......... .".....Foundation .. __ ... ... .... Prop. Line ...................... LEAS HING LIlJE ( ] 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 ( 1 Depth Diameter ...... . Numbe __-. .. Rock Filled Yes ❑ No Water Table Depth . ....-... ..............Kock Size .. ...... _.. ...-.....- -. Distance to nearest: Well . __ ......._- .....Foundation .._ .. . _. ._ Prop. Line ...................... R/ADDITION(Prev. Sanitation Permit# Date . : -....:. ..."" - �...-.."..) Septic Tank (Specifx, 'equirements) � _. _ .. ...... ........ .. ... ... .......... . "........ Disposal Field (Specify Requirements) .. r--�:....I,o"..-,rf_.f.zl<... .� ... •' - J.a. ..? - Y,. 1. _ _ ................. (Dr( :xisting 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 Son Joaquin County Ordinances, State Lows, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "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 Wcrkman's Compensation laws of California." Signed r Owner dy / C f_ c 1 / / i Tile .( Jf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE -�y . DATE BUILDING PERMIT ISSUED ADDITIONALCOMMENTS ( Final Inspection by: sn! = t SAtJ '0AGUIN LOCAL HEALTH DISTRICT E. H. 9 '.-"6E Rev, 5M.