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APPLICATION FOR SANITATION PERMIT . 7 (Complete in Triplicate) Permit �. G- ..........................�` .... This permit Expires 1 Hear From Dot*Issued Date Issued 1.� 7:ZZ f 1 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. 544 Fad existing Rules and Regulations, JOB ADDRi SS/LOCATI ,.L _. ...J! :�_...i.. ... CENSUS TRACT .......................... Owner's Norrie .. .. .l t +- .. ......... . . , .� P. .. :.. . one .................................... ...a.40.-•-•----� ---... ---• --•-•--•-.•..Address ........ Contractor's Name -- --•-- r. ..�,.QF�+ 't.y € r;:..Eicenss # .. Phone //011;KA9..lr... Installation will serve: Residence Apartment House{] Commercial❑Traller Court ❑ Motel❑other..................... ...................... Number oMr . .......Garbage Grinder _. � Lot Size ... --......�X. ..Number of living units:_--•- � �....-----.,..,.... Water Supply= Public System and name ................................_.._...._........----...............................private ❑ Character of soil to a depth of 3 feetc Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ day 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 an reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) � :� C f PACKAGE TREATMENT ( I SEPTIC TANK size...y�x... . ........ .1 ......... Liquid Depth ... ...--.............. � CapacityType , ! .f a '. Material A!f No. Compartments -,2q................. Distance to nearestc Well' ` Ls.�4:� ......Foundation Af........... Prop. Line .. ............� LEACHING LINE No. of Lines s • Length of each tens-..... s �........ Total Le th ............ 'D' Box --.. ...... .. .l Type Filter Material .. lr.''�.....Depth Filter Material ....� ................. f Distance to nearestc Well Foundation -._..,�............... Property Line ................� SEEPAGE PIT Depth _z . Diameter 3 r (�• p _._._.._.�..... Number ........sa�...........l.. Rock Filled Yes � No ❑Q r Water Table Depth ........5?e.�........---•................Rock Size ._.2..`....... ............. F i Distance to nearest, Well ----- - .. • '.........Foundation ... Prop. Line --- -------------..- REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................I SepticTank (Specify Requirements) ......................................... .................................................................. ............................. DisposalField (Specify Requirements) .........----........................................................................................................................ ...----•-•.................................•----•.....................................-----........................---.................................................................................... (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 Sara Joaquin Local Health District. Hem* 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 .... --••----- -• ........... ------------•--•............. owner Z By ...-----•--- ... ....... .. ... ......................... Title ............. .......................................................... (if other than owner) It DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE .--, o.-- -:,7� ...........:-: BUILDINGPERMIT ISSUED ..................... ...............................................DATE ....-...................................... A DiTION COMME . ....._-•--- -- ------.......... . ......... :-: :- :::::::::: Q :: : ....-I"In. ..................... .. - -.....t...-.-. .......................I... .........-...... Final Inspection by: _.. Date .. ... EH 13 24 3-6a ; AN AQUIN LOCAL HEALTH DISTRICT 8/7 +l i t