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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT . ....................•......._... . ;Complete in Triplicate) Permit No- ........-........ ......................................... . This Permit Expires ] Year From Date Issued Date Issued 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 com lance with County Ordinance No. 549 and existing Rules and Regulations: IV'All NSUS Owner's Name .. ........ ' . � -- ....-- e-------�f---- a RACT .......................... JOB ADDRESS/LOC TION N.3.._.. ......................................................_ CE Phone ... ............ ........... .---.._.....__._:..--- -----....-----•..................... 71 Address ...........7 .: `�'J� .=---- city _._.... .-•-- _ r Contractor's Name .....-. .. !+!.-� ... :-- t...14 :.._.....License # -1JSIFAP Phone .............................. Installation will serve: Residence [Apartment House Commercial OTraller Court 0 Motel ❑ Other ............................................ Number of living units:..... Number of bedrooms ....3-Garbage Grinder ------------ Lot Size .......... Water Supply: Public System and name .................... -------------------- --------------- ...................................... ..............Private Character of soil to a depth of 3 feet: Sand=f Silt❑ Clay 0 Peat❑ Sandy Loam [] Clay Loom jr] Hardpan ❑ Adobe 'er 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( ..._._._..__ Liquid Depth .............. r / COO Capacity -114-0-4Z_ ....... Type _ Material----- ---`- No. Compartments ..;,. ............. Distance to nearest: Well ........��".P... _--_-.---._Foundation ....... ././:Prop. Line . ��....... LEACHING LINE [ No. of Lines ..__.__._,ms's.......... Length of each line._-__�_1,t..___-__ Total Length ---12-.1.............. 'D' Box ------1--. Type Filter Material ........s-5_K__Depth Filter Material ......ZH................................ . Distance to nearest: Well ...... Foundation .....L.b............ Property Line ....._.. -......._.r SEEPAGE PIT Depth .... Diameter ..� Number ...........;�L.l-_....... Rock Filled Yes Er--*-No 0 <� Water Table Depth 2i4?_ ___•....................Rock Site / .X--- --��••---.-- p Distance to nearest: Well ....16-b....................Foundation ...0;?_.......... Prop. Line tJ REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ............................... ...) f1 Septic Tank (Specify Requirements) .......................................................................................................... DisposalField (Specify Requirements) ...............................--...................................................................... .............................. _......... ... ••--•- .... (Draw existing and required addition on reverse side) € hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licew sed agents signature certifies the following: "I certify that in the performance of the work far 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 By ........................... : - ----- "` ., title ..... .................................... ------------------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ' ........................ DAT E .Z�......�.��-�� k BUILDING PERMIT ISSUED ......... -------------........ ,-..__............. ......... _..................DATE ........................................... ADDITIONALCOMMENTS .......... ............................................................................................................................................. Final ................••• f e-•-----•-----------------------------------------------------•-•------ ...._....,i.... m��.I. :.................. , a Inspection by. __...eG` _._.._.••-----__-. ............................. ................................................Date -...-.--.................................... " SAN JOAQUIN LOCAL HEALTH DISTRICT "� E. H.13 24 1.'bg Rev, 5M 7/72 3 M