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( FOR OFFICE USE: �� a APPLICATION FOR SANITATION PERMIT ilc!.... (Complete in Triplicate) Permit No. x].3.:.7.. .5.. ............ this Permit Expires 1 Year From Date Issued Date Issued ..-. 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/1.0;rON ..'........ ._- / v .'V.0 : .S....-...-....":...-.-._-.- CENSUS_ TRACT .......................... Owner's Name •••---•_... r .............. ..... Phone Address ....................... .R.0...�?7../..,5._.....� ...'\_ ..17, r..- , - --- . City Contractor's Name .--..- ..........License # _.. - �.��1 ......... ....................... �7•Sj.11..... Phone�'�,��/�.. Installation will serve: Residence�rtment House fl Commercial❑Trailer Court 0 + . Mote( ❑Other l _ c Number of living units,.,... Number of bedrooms .�......Garba a Grinder lot Size�Qir.-f�!>l.''..................... I ► Water Supply: Public System and name ........................................... .................................Private` Character of soil to a depth of 3 feet: Sand❑ Silt❑ Cloy Peat❑ Sandy Loam ❑ Clay Loom ❑ Hardpan ❑ Adobe Fill Material z�.. If yes,type .................. . .. (Plot plar<; showing size of lot, location of system In relation to wells, buildings, etc. must be placed-•-on,everse side.) NEW INSTALLATION; (No' septic tank or seepage pit permitted jf,public sewer is available within 200 feet,) S PACKAGE TREATMENT [ j SEPTIC TANK i j Size............................................= Liquid Depth _.._... .................. Y v Capacity- Type ......... .......... Mbterlol...................... No. Compartments .... S .._...... t Distance to, nearest: Well .......... """'t'...................Foundation ................ Prop. Line ...... ir_�s LEACHING LINE ( ] - No. of Lines .......................... Length of each line...................... Total Length D' Box ...._.._._.. Type Filter Material ..:.....:...........Deptli-:Filter Material ... i Distance to nearest; Well ............... Foundation ......r................. Property Line ........................ SEEPAGE PIT [ ) _..�� Depth .................... Diameter Number ......r. .................. Rock Filled Yes ❑ No ❑ Water Table Depth Rock Size ............... ..----•-•• =---..-........-----__ Distance to nearest: Well ...................................':..Foundation .................... Prop. Line ...................... s REPAIR/ADDITION(Prev. Sanitation Permit# ................................:-_..-__.__.. Date ..................... Septic Tank (Specify Requirements) ........................... ... _ " ................ •- •-_...__.._......._- Disposal Field Specify Requirements` ......... ... ..............._l--o� ._._ ..... boll .. ... ...................... .. (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 Son 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 Workman's Compensation laws of California." Signed .................. .. Owner By .. ...............•----...aert ............-_... .....---... ••----.....,-•-..__....... Title ...(I of owner) i. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...,. ...... .. .. . ... .... ................... ............................................ DATE .... zf.....�.. ..._.. BUILDING PERMIT ISSUED—........ ...........:....... ..............DATE .--- .. ............_.._ .. ................ ADDITIONAL COMMENTS............................................................ .......................................................... ................................................................ ........-.._____-._...........-•- ...................•......._-._..._......_..__:............----- .......................•-----.. _. -. . ... Final Inspection by: ate ..........oR-a----- _ qz�3 -•••--••••-•-.. .... .............. ..... ............................ SAN..JOAQUIN LOCAL.HEALTH DISTRICT E.H. 13 241-'68 Rev. 5M 7 1'7 1) z w