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FOR OFFICE USE: xArOLICATION FOR SANITATION PERMIT € -------------- ------------------------------ -------------------------- :-' (Complete in Triplicate) Permit No: .___ '�/ ------ ------ This Permit Expires Date Issued -9--/6--7-� - - xp�res 1 Year From Date Issued plication is hereby'made to the San Joaquin Local Health District for a permit .to construct and install the work herein afesaibed. This application is made in corhp11 nce ith County Ordinanae No. 549 and existing Rules and Regulations: JOB ADDRESS/L p N -__ - - ----------- CENSUS TRACT --S 7 Owner's Name ------ ------ ----- --- ---- - -- --- - - one Address ----9 p -- _ --- -- - -. -- -- ------ ----. City i -- ----------------- ----- Contractor's Name....... •---- - _ :__--- -----License.# � "Phone ------------------- Installation will serve: Residence A rtment House Commercial -- ❑ oTrailer Court I] Motel ❑Other--------------------- age Number of living units________ ___ Number of bedrooms ______Garb =Grinder ---.__------ Lot Size ----------__-'__-- - - ------ 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 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.) INEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ?ACKAGE TREATMENT [ ) SEPTIC TANKU Size ------------------ ------------------ ----=- Liquid Depth ---------------------- - 4 Capacity ------------•--- --- Type ------------------- Material.--------- ........... No. Compartments •-----------•---_ Distance to-nearest. Well ------------ -=-----------------Foundation--------•------------- Prop. Line ------------- - LEACHING LINE [ ] No. of Lines ----_----------------- Length of eachline---,._•--------------------- Total Length . f ---------------------- - 'D' Box ------------ Type Filter Material ----------.------.Depth Filter Material Distance to nearest: Well ----------------------- Foundation ---------.__----------- Property Line SEEPAGE PIT [ ] Depth Diameter --------------- Number ----------•----------------- Rock Filled Yes Q No.l] Water Table Depth -------------------------- _......... ---Rock Size - - -- Distance to nearest: Well --------------------------- _ ----Foundation -------------------- Prop. Line -----._.____---•-_- EPAIR/ADDITION(Prev. Sanitation Permit# ----•------------------------------_ Date ------------------- ---- --------- 5 ( pecify Requirements] 1 Septic Tank --- - _- - -- - - - --- osal Field (Specify Requirements) - - C .- - - ---- --------- ---- --------c - - - - - -- - --------- --•------ - - -- -_ - ------- ---- ----------- - - = - -- (Draw existing and requi addition on reverse side) 7 herebY certify that I have prepared this application and that the work will be done in accordance with San Joaquin saunty Ordinances, State taws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- 'sed agents signature certifies the following: certify that in the performance of the work for which this permit is issued, I shall not employ any person. in such manner ., to become subject to Workman's Compensation laws of California." Signed . ---- --_ Owner rte. -- -- - _ -- ------------------•-for - --n_ - � t Title �`�"`>� llf other,than owner]� - -- -----""•'-- F_OR DEPAttTMENT USE ONLY PLICATION- ACCEPTED: BY _- ------------------------------------------ ----------------. DATI< .3_-_� __'. - ILEnING PERMIT ISSUED �.---___-- ---------------------------------------------------- - -- --------------DATE -------------------------------- --------------•----- ----- ,ADDITIONAL COMMENTS ________________----------------------------------- __________________ _ __ - -- ---_------ -- -------------------------------- - --- - - - ---•------------------------•--------------------------•-•--------------•-- - ------------------------------------------- - - - - 7na Inspection by: _.--_- -- ------•--- - ---- - - - - Date , SAN JOAQUIN LOCAL HEALTH DISTRICT • �� ., . .�., ., .... Ltd-----�~ -