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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. {Complete in Triplicate) p• 6 3-;7V ......... This Permit Expires 1 Year Frain Date Issued Date Issued l.-'.... ....._ . 2 7 moo., 6t o4- �T- Dcs'- mac) —t 7 Application is hereby made to the Son 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: ,2S .__G . .._. .._. . /cs'r.-.... .l�.1/./.... ........... —CENSUS TRACT .......................... JOB ADDRESS/LOCATION . . .- Phone Owner's Name - ........ '......... .-------- . .. ---- ............... ............ Cit-------- ....._ .......__................ Address ...... --- .- Y g o / .... r" ...... Contractor's Name - - _ _ `----------.License #lY Phone ..................... Installation will serve: Residence ❑ Apartment House,p Commercial ❑Trailer Court ,[] Motel ❑Other .. ---------------------•• Number of living units: . .._-..- - Number of bedrooms .....-------Garbage Grinder . _ Lot Size ......................................... Water Supply: Public System and name - - -------------- -- ------------------- ---- ............... ------••- Private GR/Character of soil to a depth of 3 feet: Sand❑ Silt ❑ Clay E] Peat El Sandy Loam Clay 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.) -J 5 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) M� PACKAGE TREATMENT ( ] SEPTIC TANK,( ] Size----------- .............................. ..... Liquid Depth .---......... 1 Capacity Type .................... Material.......... .. No. Compartments ................ Distance to nearest: Well ........ ................ Foundation ....- ------- ....... Prop. Line ------- .......... LEACHING LINE ( ] 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 ( j 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 -...------.-.-.------------------.1 Septic Tank (Specify Requirements) . . .. ..... . ............. ------- ------ ------- ----------- -------.._......._._. -------- Disposal Field (Specify Requirements) �' . Via "..�..... A ,.s....�...1Q ............................................................... .... .... ------------------- _------ (Draw . .(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. Horne 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 WorkmKCo' nsation laws of California." Signed .. . . ---- ----------- ---- ---- - Owner By _ . _.. Title .. ................... ... (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . ✓ Az.GG ........I.. .... ----- DATE . �.... / BUILDINGPERMIT ISSUED .... . . ..... . ... .. ... ........ .. --...-------- - .- .-..._DATE _. . ..- ............................. . ADDITIONALCOMMENTS ---• . -•-- -- ••. .....--•--• . ................ .-- --------.. ...--- . ....... ------_-------- _............... .. . .. ... ................_....... ........-------......-------- ------------ ..--...-----...__....... -_-------- ---------- _ Final Inspection by -.... ----....-Date/D-- ---..--._ ... /// SAN JOAQUIN LOCAL HEALTH DISTRICT co ° 3 413 24 7/72�� m »� N 1.'(,R Rev_ 5M *_ .... ... ,'._ -