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--- FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT1W67 —. � Permit_ No. ......................I-------.-------- (Comp"in Triplicate) x x� 1 Date Issued ..7- 3.7. .... a This Permit Expires 1 Year From Date Issued ... ....................... Application is hereby.....--......made to the Sa'n 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: JOB ADDRESS/LO TION /...-....... s .. ............. -�-- f ...... CENSUS TRACT o �-: Owner's Name -1 .... i. ..................... ........••••. ..• _...:. _ Address ,.-.. •-- .. Contractors Name License Phone :.. : ..`..... Installation will serve: Residence P4partment House Commercial ❑Trailer Court ] Motel ❑Other ------------------ :...: r Number of living units:__--------- Number of bedrooms --- -----Garbage Grinder ....-_- ---- Lot.Size-----_ Private Water Supply: Public System and namie ....'..... ........... .. Character of soil to a depth of 3 feet: Sand 0 Silt[] Clay ❑' Peat C3 Sandy Loam 0 Clay Loam Hardpan ❑ Adobe ❑ Fill Material -:_____.__ if yes,type .................. showing ize of lot, location of. system in relation ta•wells,..buildings, etc.. must..be placed on reverse side { (Plot plan, 9 s NEW INSTALLATION: ! (No septic.tank or seepage pit permitted if public sewer is available within 200 feet,] .E t PACKAGE TREATMENT ( ] 'SEPTICi�ANK-1 ] Siza.................•-••-•-....... -•--•-. Liquid Depth .;:. ................. - , .......-..... Capacity ..� Type ..................... Material- No. 'Compartments ........ nearest: Well ..Foundation -•---•...._...... Prop: Line ............. ....----•.:...-- .... _ Distance to Weare Total Len th" ............................ LEACHING LINE [ ] No. of Lines -------------'-••-----.. Length of each line-----_------_-- g 'D' Box Type;.Filter Material Depth Filter-Material .................. / Foundation Property Line ........ ............... Distance to nearest: Well ..--------- ..•_.... t De th ...; Diameter ... Rock Filled Yes No Q SEEPAGE PIT p ..:.--•-•------- .- l1.11-•---...Rock Size ...,............................ W9ter Table-Depth..--•------ k iFoundation .------•------••---- Distance to nearest: Well -••-•--••_ •-• '•"•-"""- ....... Prop. Line ri#anon�Permit }...... k-Date .....•- REPAIASa ] i - Septic Tank(Specify Requirements) ----------- ........ ................. ` ------....----......�. ---- ...... ------------- -1 a h/ Disposal field (Specify Requirements) ` - - - ........................... .�• .-- ------------------ • side) 1 . 3 (Draw existing and required addition on reverse ,,_ # I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin - ; . ._ f County Ordinances, State Laws, and Rules and-Regulations of the Sari°-;Ieaquin Local Health District- Homeowneror icer- ` sod agents signature certifies the following:. "I certify that in the performance of the work for which this permit is islued, I shall not employ any person in such manner -•was to become subject to Workman's Compensation laws ,of California. Si ned ----------•- ... ....... - Owner #.T. 9 ....... .. .........' _ ` Title (1 other than owner) y ' '. f E , FOR EPARTMENT USE ONLY AT .................. . 1r, DATE .:7`..� ....................•-------..... ........... APPLICATION ACCEPTED BY ,._-.. . '---------- - -- --------•-•- ................................. BUILDING PERMIT ISSUED •------------ '` _... _ ... �......_......_. ADDITIONAL COMMENTS == ...... ... ---' - •- S .... _. ----....... '.. at • -----.... `-D e .. k - Final Inspection by: -- •---••-..---- SAN JOAQUIN LOCAL HEALTH DISTRICT} `4- `7172 3 M _, .. 7 � 7li r gad o_.. C►1 - - - — __. _-