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, FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.� ......... ......................_......_..__......... . •�..-�`�..'. (Complete in Triplicate) Date Issued _...r...........:. ..............................................I..---... This Permit Expires 1 Year From Date Issued , Application is hereby made to the Son Joaquiri Local Health District for a permit to construct and install the work herein Regulations- described. This application is mode in compliance with Cou ty Ordinance No. 549 and axis 'n , ales and Regulations: - A , ` / .- a p._.... `sem I NSUS CT JOB ADDRESS/LOCATION ........._ ..-__��L'...-.. 11..�s---, .-. .•a_. �. r� Owner's Norrie �r.x,, l mm^ ./...L.L.L. .. ....Su ....................... Phone. .._....... rL-Address ............. , . ........ City ............................... . -.� ........................................... -- Phone . . - ---.Contractor's Name ......... ..----.License # Installation will serve: Residence gJAIrartment House❑ Commercial ❑Trailer Court 0 Motel ❑Other ........................................... COO Number of living units------------- Number of bedrooms _;.. ....Garbage Grinder s---- Lot Size ._ ., •••---• .. Water Supply:.Public System and name ----------------- ------ -------------•----•-------------...._..-----------..------ = Private Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 k 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK i ] Size...........................-.................... Liquid Depth ..........._...._... .....00 ' ... Capacity ....... ........ Ypa�-----._............. Material..__.._..._..__. ..... No. Compartments ...................... F Distance 4o nearest: Well ....................................Foundation:,.-__----.- Prop: line ......................10 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.......I............... Diameter ............ ..:_ Number--:n..........._...`......... Rock Filled Yes ❑ No ❑ WaterTable De th ................................................Rock Size ......:..._-.-----•---------•--• ,6 Distance to nearest: Well ----------------7-- __------............Foundation -----------......:.. Prop. line ...................... REPAIR/ADDITION(Prev.-Sanitation Permit# ::............... Date ..................................I Septic Tank (Specify Requirements) ......:........... ..----- . .................................... ...---- .....---....:.:......---- .... ------ ---•--- Disposal Field (SpecifV Requirement ) .t:...... ... .. .. . � . �!g' /may - ...--•-•------------••- ---•--•............................................- (Draw existing and required addition on reverse side) i - I hereby certify that I have prepared this application and that the work will be done in accordance .with San Joaquin f Ceunty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Iicen- I 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 bewme'subject to Workman's Compensation laws of California." Signed...............I------------ --=--------------- -- =-- - .......:-- Owner By ....... - ............... .............. -_-,-------------------. . tie . _.._._..... . - - %# (If of er an owner) /FOR-DEPARTMENT USE ONLY I APPLICATION ACCEPTED ....... . .:.... DATE ..-3.:��: %ZS.................... BUILDINGPERMIT ISSUED ..........:..•..... .............:.......•-----•. --•----= ...:........... ........-DATE ...................................... ADDITIONALCOMMENTS .................... ..............................................-----------._._...•--.........` ........ ........................... •-- :.-------:...:._.-..............-••-----........:..---------•---------..._...---._ .. ...... .................. ... ...... t. ------------------------------------ ---- .....--....................................................... --•---....__........ ................. € Date ..... Final Inspection by: _. ...... :.... SAN JOAQUIN LOCAL HEALTH DISTRICT 7/723M