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FOR OFFICE USE: _______________ PPLICATION FOR SANITATION PEk` ,.T -7 (Complete in Triplicate) Permit No. This Permit Expires 1 Year From Date Issued Date Issued- - --- -------1 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. 5499 and existing Rules and Regulations: / y_LIL __ __JOB ADDRESS/LOCATION -___ .__CENSUS TRACT _______________________-- - 7f�b--Owner's Name . -------Phone _6Y-3 .� ------- ` Address ------- — ----------------------- Cit --------------- ----------------...-•--------- Contractor's Name It ----------------------License # --/-U-- ' .1.-- Phone = y --------- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ,❑ Motel ❑Other . - ------------------ } Number of living units:__ �. _ Number of bedrooms _3...---Garbage Grinder LSD____ Lot Size __�7-�__ _ .1--`---------------- Water Supply: Public System and name --- --- ------- --- ---- - ---------------------- [ -- Private �. Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam . Clay Loam ❑ Hardpan ❑ Adobe FFill 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,) r � J PACKAGE TREATMENT [ I SEPTIC TANK M Size.__.___��_C _n__ Cc_f____.-_._._ Liquid Depth -- '-_/_______.__ Capacity _� "Z 7-- TypeMaterial _____ No. Compartments--a ___ ------ � Distance to nearest: Well __.____,- i_________________Foundation ____L_�__ _;____.___ Prop. Line __7____________.-___ LEACHING11NE [ ] No. of Lines ._._ _ _ _ Length of each line_ ___ __ _ __ ----- Total Length . _..___._-_ 'D' Box .... _ Type Filter Material _ -- _ __-----Depth Filter Material - ___________________ _.- Distance to nearest: Well ...... %.4' _ __ Foundation ___/_r1'______ _ Property Line ---------.__..-----_ SEEPAGE PIT [ ) Depth _ _ __ Diameter -... _ .___. ------------------------- _. 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) --------------------------------------------- ------------------- - - - ---- --- - -- - -------- - =--------------------------------- ------------------------------ - - ------ --- ---------------------•- -- - ----------------------------------------------------- - --- (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. 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ata a!v Owner By - f� "1 G :i+�c� • . - ---- -- - Title (If other than owner) FOR DEPARTMENT USE ONL- .. APPLICATION ACCEPTED BY .___.__:_ ---- �� DATE __.._..._. - 2-- 2 Z` ------------------------------------------------------ �G ------------------ BUILDING PERMIT ISSUED -------------------- ----------------------- r ---- -- -------------DATE ----- --------- ADDITIONAL COMMENTS -------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------I----------- ------------------------------------------------------------ -------------------------------- ------------------------ ---------- ------- - ----------------------------•--------------------------- --- -------------=------- Final Inspection by: -------------------------- ----- ------------------------------------------------------- -: Date - �� bm SAN JOAQUIN LOCAL HEALTH ' TRICT L F H 9 1-'F)R Rav 5M