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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT -- ~ n_.... Permit No: 7Sj� f ;........."�... .. 7 l (Complete In Triplicate) _.._...._.... sl.. ..........9:...... ................... n This Permit Expires"! Year From Date issued Dat 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: A. / JOB ADDRESS/LOCATI N ..: / �f/ �T-21 F'".�9... ......;....,CENSUS TRACT Owner's Name ... .. ...r..._��e�-)[.1...... .......... .. ...�• .... ..................................*....................Phone .............I...................... ............ ........I ;Ikf. 1 N ` ---.... City ---------------------------------------- Contractor's -•- -- --- -- .. ..I—........... �i.T.� Imo` / ` Contractor's Name .... z'� - ---•------•--•----•-•--..License # .........:.........�.. Phone ............ . Installation will serve: Residence ariment House❑ Commercial []Trailer Court 0 J []Other . . Motel ......---•-- ....................... Number of living ' ,�units:..._ Number o ro .�- s . __.Garb ge finder / ... Lot Size .. `� .� .�......... i.... m Water Supply, Public System!and name . ��_... Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay %,,Peat❑ Sandy Loam ❑ Clay Loam [3 JM, Hardpan ❑ Adobe ill Material ............ If yes,type ............................ ; (Plot'plan, 'showing siieFofl�lot, location of. system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTAI..ATION: (No:septic tank or seepage pit permitted if public sewer is available within 200 feet,) 0 { PACKAGE TREATMENT [ ] �ISEPTICTANKI ) Size.........................................`....... Liquid Depth ......------•----._.......- ___.. Materia! .. No. Compartments I Capacity ............. ...... Type --------•-•--•- -----------...-•---• P ...................... . Distance to nearest: Well ...............................:....Foundation ................ Prop. Line _-------•------_.... Vk LEACHING LINE [ j No.. cf Lines ........................ Length of eachline.-.--................. Total Length ...._.. .................... l 'D' Box ...... Type Filter Material ................Depth Filter Material ........................................ F - Distance to nearest: Well ........................ Foundation ---.__.--_---._.___---•• Property Line . . �• SEEPAGE PIT [ j Depth -------------------`- Diameter ................ Number ...--------................. Rock Filled Yes ❑ No C3 Water Table Depth Rock Size (� Distcince to nearest: Well ......Foundation ..... Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. Septic Tank (Specify Requirements) ...................................- _.... ... iDisposal Field (Specify R'� :rements) ............. ... --------------------- -- ................�� ---------------------------------- ........................................--............. ----- -- --•- ---------•------- ---• -----------------------------•-------•-•----........_...•-----.....-•--- ' (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. 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." t f Signed ................ --------'�l-- . Owner . Title ............ ... (If` r than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .....---. ..... ----------------------------------- DATE .��. . BUILDING PERMIT ISSUED .2!1......................._---_.... . ._... :.:............DATE ADDITIONAL COMMENTS ...LI: - .............. ...........--- ........................ �I' ., `....- ......... .............I............................................... . ................--••--.............--•••-...._._...._.. Final Inspection by: dl, ...................... : .Date .-.: -Q:.. i i 111 SAN JOAQUIN OCAL HEALTH DISTRICT I� 1 E. H. 1-3 24 1-'68 Rev. 5M 7/72 3 M