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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT !......... .............................. Permit No. -7,�. .l. (Complete In Triplicate) ' .....................:........................ ...................... This Permit Expires 1 Year FromDate Issued Date Issued ./...�............. I 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: �• �•-- _.......CENSUS TRACT f JOB ADDRESS/LOCATI -.� ' � ., ..... ........ ....... . _ l +,..: Owner`s Name_"..: !Y/r%. . _ ..-••_... ... .,T..--- • Phone, .. City ` , . Address .:.. •' s .. Contractor's Name . �_, �d 1.. :.license #I� Phoria"" _ .........: .... Installation will serve: Residence Apartment House Commercial []Trailer Court fl --- �. . s Motel:r7 other Number of living units:............ Number of,bedrooms . rte'" --._Garbage Grinder :........... Lot Size ....... ............. ----.......: Water Su I 'Public System and name ' ......:.....................•-•- Peat~ _Sand pp Y�„ --- ................Private Character of soil to a depth of 3.feet.. Sand 0, Silt❑ .- Clay. ❑,,� � 1];,,�, s Sandy Loam Clay foam 1❑ ;,,„,,:� .- ._. -Haidpon Q Adobe ❑ Fill Material _ lIf yes, pe ----------------------------- F ty _ (Plot plan, showing size of,lot, .location of..system in relotion..to.wells; buildings, .etc-.;must#.be...pioced'on reverse side.) NEW INSTALLATION: (No septic tank or'.seepage pit permitted if.public sewei.is available ' ithin 200.feet,) ` .. Siae --_:- Liqu epth PACKAGE TREATMENT ( ]: SEPTIC TANK I j -- ••• D ` , + Material. No. �Co partments . . ......... .............§ 1" F Capacity . ............. Type: -•---•--.......--•- .. , . 6 . .� ,. .Foundation Distance to nearest: Well :._.._ Prop. line ..--•--...._.... LEACHING LIN - E ( j No.�of,Lines -------•• Length of .each liner __ - _._. Total' i.erigth ' 'F Type Filter Ma#aria)'' Depth Materibl .....,-. ••• ......... D' Box .... ; Distance-to nearesti Well. -.:::.:.•-_' --_ Founclationi.—.- ._ Property L _..._... P Line -•./ ....: Number Filled. C] . SEEPAGE PIT [,t[ .j ..... • . Depth Diameter Rock, ills •Yes No [ � { � Water Table Depth: . Rock Size. . .. ... ._.;. i ...._ .. : Distance to neatest:,Well ::.Foundation _ _ Prop line i< REPAIR/ADDITION(Prev. Sanitation Permit --._. . .- -- --•-• . •. Date y. -) Septic Tank (Specify Requirements) ... _. ................. •-;---.. - - ...... Disposal Field (Specify Requirements ......................... ....--- l.. ----- ---------•-•---------------•-- _ -- ....... ---•----------------------- ... _ s Draw existing and required addition on reverse side) w�. ,•„• r,„ `-, .•; _. , I hereby certify that I have prepared this application and That;the work will be done m 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, 1 *hail not employ any person ie s h manner as to become"subject to Workman's C ensation laws of California." _. - - { Owner gdSi .------y..... ----• .......... By ...... - . Title (If other than owner) e f iFOR DEPARTMENT USE ONLY . o APPLICATION ACC!"PTED BY . .�: .....: ;._._....... BUILDING PERMIT ISSUED s. E DATE DAT ADDITIONAL COMMENTS ! .._. ........--- - ... ' = .............. . y . n t....... ......... ................................. .. ... - ...k.......... .. .. .. ... , .. ......................................... - Final Inspection by: .' �° .. ••... -Date . � . ; SAN iOAQUIN LOCAL HEALTH DISTRICT ' �. . 13 26 , -An n_.. cal -