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f FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �-•.. ...... ............................... Permit No. .:.7�" (Complete in Triplicate) ......................I............_ ,. This Permit Expires 1 Year From Date Issued Date Issued l 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: JOB ADDRESS/LOCATIO ._...... . .. - _ -- `..............,:. {�1.�..!.S.�r--------... --• .............•---CENSUS TRACT ----............. .... : Owner's Name ----- � � . G--. r. .................... ----------- ......Phone Address ,..._. .. C,•....�2............... ............ ------------ City Contraetor's"Nome ......... ................... _.....License # Prone .. Installation will serve: Residence 0 Apartment House❑ Commercial ❑Troller Court F] s Moteler I Number of living units:........... Number of bedrooms ------------Garbage Grinder ...._....... Lot Size .........._...__.._c . . ..... . ... FWater Supply: Public System and name ............... -------------------------------- .-.-.._..-.--..-A.........---------- •............Private �. Character of soil to a depth of 3 feet: Sand Silt❑ Clay El Peat.❑ Sandy Loam 0 Clay Loam ❑ —� ';,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 seeps it permitted if public sewer is available within 200'feet,) PACKAGE TREATMENT [ SEPTIC TANK Size-------............................/.._......._ Liquid Depth ............. ......... Capacity )S490.. __ TypeU—' Material<�6 7.... No. Compartments ------- .............. Distance to nearest: Well . ...gip --------------------Foundation . .... Prop, Line .._ - `. LEACHING LINE [[,r-"'No. of Lines Length of each line -- ! g 7C�.. ............ Total Length . ��, 'D' Box E Type Filter Material - Depth Filter Material -.-_--� .�--� ---. ,._- __......._.._-•- Distance o nearest: Well _._.Cf __...._ Foundation ..... .f- Property Line ---__._._._--__ SEEPAGE .. PIT [ ] Depth } . Diameter ........... ... Number . ..._.. .... --............ Rock Filled Yes 0 No 0 i Water Table Depth ---- --- --- ....... .........0......Rock Size ..... I Distance to, nearest: Well ................. ------------- Foundation ...-........ ...---- Prop. Line .................. I REPAIR/ADDITION(Prev. Sanitation Permit# ............................--------.------- Date ..........-------------- --------J r Septic Tank (Specify Requirements) ............. . f Disposal Field (Specify Requirements) ------------------------------•--- ----------------- ...... ---------------- --- ------ -------------------------------•------.._._..._...----...._.- -------. ----------------------------- -------------------- .................. ------ •--•----------•----..._.-- . ................ .. ... ....------------_... (Draw existing and required addition on reverse side) 1 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin I County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Nome owner or (ice". f sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner i as to become s bject to Workman's pens9tion laws of California.- Signed alifornia." Signedr`�-.. . ---------------------------- By -------------------- -- Owner r By : - - -------------------- ......... ...........-_. ... Title . (If other than owner) t APPLICATION ACCEPTED BY ...._.._... . -------........................... ...,.., DATE .t- -., ............ ' BUILDING PERMIT ISSUED .............:!. ---------------- -------�---------._.----.....--------------....._.... .:. .-•-••--......DATE ........................................... ADDITIONAL COMMENTS _ ---- --------- ------------------------------------------ E ----------------------•---------------------------- ------ ----------------------- ----- .--- .....-- .......----............._... ---......... ` Final Inspection by: ............. ...................... ............... .....------ ....Date . ...... ` ................... I i SAN JOAQUIN LOCAL HEALTH DISTRICT l� 13 2 _ 7 E. H. 4 1-'6B Rev_ SM 7172 3 m