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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .7� y ICoreplete In Triplicate) Permit No. ................. ..... .................... ...... This Permit Expires t Year From Date Issued Date Issued ./..`I:�:�:".72 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: 10B AbDRESS/LOCAT10 - Q . ............................. ......................CENSUS TRRAACTT .......,.................. ! Owner's Name !- .......................... Phone '.!-C1 �.. 1 ...._..,. Address _ � _.. City .. :...................... L ........ Contractor's Name .............. ........... . . .... ..... ........0 ...............License # .7.T 1-3... Phone ..... ....... I Installation will serve: Residence❑Apartment House C) Commercial ❑Traller Court C] Motel ❑Other ....................•..... ................. . Number of living units............. Number of bedrooms ... -__....Garbage'Grinder ............. Lot Size . ez ....................� Water Supply: Public System-and name ...........Private 'Character of soil to a depth of 3-feet: Sand❑ , Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ , ° W. Hardpan 0 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 perrnitted'If public sewer is available within 200 feet,) .PACKAGE TREATMENT ( ] SEPTIC°TANK I ] _. 1 Size...............•---.................. .......... Liquid Depth .......................... Capacity . ... Type -- Material................... No. Compartments Distance,to nearest:. Well ..................................:.foundation .........ti_:......... Prop. Line ...................... y k ` LEACHING LINE [ } No. of Lines ............. Total Length . -�--`-"................. Length of each line............................ ...... .................... 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT - �'- - - :.�:_ ( } Depth --..-...._......... Diameter ...... - Number .......:.................... Rock Filled Yes ❑ No CC! Water Fable Depth ------.•_-.-. ..........Rock Size Distance to nearest: Well ...Foundation -----. ....11....... Prop. Line ...................... REPAIR/ADDITION#Prev. Sanitation Permit# - Date ..................... Septic Tank (Specify Requirements). Disposal Field (Specify Requirements) ... I ----- ----- •------ -----------------------------_-----------------------------------------•----...-----..--.....:--••--.....--.--•.-•-•--•--. {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 }y County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Homo owner or licers- sed agents signature certifies the following. 9 "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 - ------ r Owner By ..-.. --------- -------------_--- .... title . ..-----....... --......----- ...-----....--•-- th an owner l _ - FJPk DEPARTMENT-USE ONLY � APPLICATION ACCEPTED BY --- DATE >.>� . 2 r: ....: BUILDING PERMIT ISSUED -...-....+: ....... DATE ............................... ...... ADDITIONAL COMMENTSticn.� l ........- dQ. .r -.5 - ...... .................... .....................I...........--..-............................................_........ .......... ------•-------------------• ------ ------- . -- • 1 inai Inspection by: .-_____.•--•___--- Date .... El[ 13 24 1-58 liev• 5m ' SAN J AQUIN LOCAL HEALTH DISTRICT V//7b 3M