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F( R OFFICE USE: APPLICATION FOR SANITATION PERMIT _....... .... 7�- 6-7 ....................................... (Complete In Triplicate) Permit No. ...................,. ---- -- •---•-------••-•-•-----•...................... This Permit Expires Z Year From Date Issued Date Issued . ..�6.. � 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 .-.0---- -�-...... �. _CENSUS TRACT .......................... Owner's Name _l�'.-.--- u ` -----------•--_-_--------- ?. ..._.Phone Address o1. -------------------------------------- City . _- - ------------------ Contractor's Name ...... --•-�------------•-------••---------••-•.........................License # .--•-• ---...------•---- Phone .............................. Installation will serve: Residence ❑Apartment House f3 Commercial ❑Trailer Court Motel ❑Other ....................... Number of living units: . --------- Number of bedrooms ............Garbage Grinder .......... Lot Size ........................._.................... _ Water Supply: Public System and name ........................................... ........ --------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat p Sandy Loam Clay Loam p Hardpan ❑ Adobe 0 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 i J Size-------...................... ................... Liquid Depth .......................... Capacity g ------ Type . Material No. Compartments Distance to nearest: Well ....... ........... ..............Foundation ....3.........._. Prop. Line ...................... LEACHING LINE [ J No. of Lines .._�°� Length of each line. _ -6-•••---- ------ Total length ---�_ ..d--------.-•-- 'D' Box - "��. Type Filter Material f�� ." h- Filter Material .................................. Distance to nearest: Well /` .. Foundation _Jr/47.._ -- Property Line ` n�? --------- SEEPAGE =SEEPAGE PIT [ J Depth ..__.-----_...._. Diameter ................ Number ............................ Rock Filled Yes ❑ No C] Water Table Depth ---------•.................•--•--•--•---•-•---..Rock Size ................................ Distance to nearest: Well ..•....................................•Foundation .................... Prop. Line ........._--------__ REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ............._--------------------) SepticTank (Specify Requirements) -- . --------•------••----------------------•-••---......-•------------....-_..._...-•---------•-----............-•-.................... Disposal Field (Specify Requirements) ............... •............................•---•-•........--------- --------------- ------•----•--••-••-•-••--------............-•----•----•--...--•---•-•••-......•-••-••-----.---------- ........................ •••••-••••-••--------•-------------------------------- ---- I----- - -- -- --- - -••-•---.......... .......-............................... .......................... ---•-•--•--•----....•-••--.----- (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 Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "1 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 bec me subject tt/Work man's Com ensation laws of California." Signed ..... - .. ...._ ------. -- •--- Owner By -• x-c 'Q--- CR '�fitle ... . _...... . _... . (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ....` --- ................... DATE ... ----• --- . BUILDING PERMIT ISSUED CC'! � DATE . ...� ... _. ..... - - ADDITIONAL COMMENDS _. .....-.-.. ..�--. .._--G� ---• ---- --- ..Gt. c.......�..l IL ....m��.{.- - : .............._.............••--• .••... ........ ........................................ . t. �.- `+ -•............. .... ......... ... ....... _ o - -� . ..... ... ..... ............� Y� .... _...... ................. Final Inspection by: ....._._._.. • . _..... Date........ `- ............. Eft 13 21 1-68 lieu. �+�6 SAN JOAOUIN LOCAL HEALTH DISTRICT 87[1 3M