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FOR OFFICE USE: APPLICATI N FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ..... . ._.� _ -.•-•........................................... This Permit Expires ll Year From bate Issued Date Issued ....7` r.79 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 CountyOrdinanceNo. 549 and existing Rules and Regulations: L. .............CENSUS TRACT .....--- JOB ADDRESS/LOCATION ...... �+ - �.__/............. Owner's Name ....... r,-tv ....... --------------Phone '�` "� 3 Addresses .............. ..........""._ ..----- -- ------------• ---._ City -1 •- .........-.---...---�`.-...------•---.....--------.................. Contractor's NameT 'f` .�. ��-��s�.. .' • a :. .... � .....License # ...............-. ----- phone 9 ( ;;, ._ Installation will serve: Residenc ]Apartment House C] Commercial ❑Trailer Court '❑ Motel ❑Other ..........----- ------ Number ----Number of living units:_. . ...... Number of bedrooms 2--------Garbage Grinde ...-.,..- .. Lot Size ....................... ............... Water Supply: Public System and name ._...._.... � -_---- -.N!-�__.. Private ❑ . .'.----- ............. \ Character of soil to a depth of 3 feet: Sand❑ Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ........I--- If yes, type .............. (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc.. must be placed on reverse side NEW INSTALLATION: IN o septic tank or seepage pit permitted if public sewer is available within 240 feet,) PACKAGE TREATMENT SEPTIC TANK- Size....•------------------- Liquid Depth ..........._...__._....... Capacity _.._ - - --. - Type _.__..".:.----,-_-.. Material.:_..-...w._ .._-�_.-No...,Compartments ...................... Distance to nearest: Well ... _.......... .................Foundation ......................, Prop. Line ...---.......__...._.. LEACHING LINE [ ] No. of Lines Length 'of each. line . -------- Total Length ............................. D' Box _. .. Type Filter Material'"'"___j ___-__-Depth Filter Material ------------- ................. Distance to nearest: Well ---.."-----------------. Foundation ......_....._ --- Property Line .................... SEEPAGE PIT ] Depth ._ ........ Diameter Number . ---=---------- .........._......- --. Rock Filled Yes ❑ No (� L Water Table Depth __.......-- ` ...'-------.�.--••------ •---•---•---Rork Size ...............:................ Distance to nearest: Well ..._..----.-.- •---------------------•Foundation ............ ..... Prop. Line ._....._.. ........... REPAIR/ADDITION(Prev. Sanitation Permit# -------- ---------- `....._..._,______.__ Date -..-._._._._.__----_-______,-.-_..) Septic Tank (Specify Requirements) �Disposar'Field (Specify Requireme d 5.-[.•.•.-•.�- f --_.. _ -. . . (Drdw 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 County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Harte owner or.licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject-to Workman's Compens"n laws o California." R Signed BY ................. ...... -- .-... :- . ...... Title (If other than owner) DEP TME T USE ONLY _ APPLICATION ACCEPTED BY P-Z,.... . , .......f..__...._..... DATE . .f'�� . : ..,_ ...... ... .. --- � ...... ........• BUILDING PERMIT ISSUED .._._ ..... .. _!..__"_. . -- .. DATE . ADDITIONAL COMMENTS .... ..... .. ..... ...... . - .............................. -------------••------•---------- - -- ------- ----- ------•---•- -----------_-.._._.. ................. ..._._..._........ Final Inspection by; ..................-------•----- •----- ....Date -----........__ - SAN JOAQUIN LOCAL HEALTH DISTRICT L3 24 I E. H. 1-'68 Rev. 5M 7/79 'A .V