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FOR OFFICE USE. l/� � —� ` APPLICATION FOR SANITATION PERMIT ..._..._._ _�, �y�_..-....__._.................. _ `Complete in Triplicate) d.• Permit No. r � •••---. This Perrrrit Expires f Year From Qata issued Date Issued 110_ 4 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 Count rdinonce No'. 549 and Isting Rules and Regulations: JOB ADDRESS/LOCATION.Owner's NomeCENSUS TRACT .................... -.. �`� t?7 rte._...... Address ............................. ....--•----- one ... ._.......... .. ..�_._..... f ._... . , City .� Ph ? � .. Contractor's Name r ...................%-=, - � �C �,��• License # ...................... Phone Installation will serve: Residence Apartment House Commercial[]Trailer Court } p 4*\ ❑Other Motel •---------- -------------- ------ � \ i � \ • Number of living units:.*,.- Number of bedrooms Garbage Grinder Lot Size Water Supply:.Public System and name ....... ._. ...c " '`�............. . • Character of soli.t . .............. .......... . ___........_............_...... ....................\I'rivata o a depth of 3 feet: Sand 0. Silt❑ Clay p Peat 0 Sandy Loam ❑ 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 seepage pit permitted if public sewer is available within 208 feet') PACKAGE TREATMENT I ] SEPTIC TANK ] . . Size.:....................................... ...': Liquid Depth - Capacity r Type -------_---------- Material...................... No. Compartments Distance to nearesk Well ........ ...........................:..Foundation . LEACHING LINE [ ] No. of Lines -------------- '.__..... 'Length of each line............................ .............. ... -- " .. . 1 -_ . Total Length - ....... ........_..... 'D' Box .._...._ ... Type Filter-Material ...Depth Filter Material y Founda Distance to nearest: Wali .................. tion ..._._ Property Line ;.... SEEPAGE PIT J Depth ............:..: Diameter ......_......... Number ..._. Rock Filled Yes N Water Table ....................... � o � --�..�.. ble De th ........Rack Slze ..:............:... � F Distance to nearest: Well ..........'._ .. -.. .....Foundation ........... ........ Prop. Line It (Prev. Sanitation Permit#... :. .._... ....___....---.....: .Date .......................... ..�..... Septic Tank (Specify Requirements) __-: .2iZ41'�!! :G-.. ........... ................................ Disposal Field (Specify Requirements) �,? ? Q,Cdjt*'X! ,�/� .. .~ . e ---- h _....__._..- .Q �rH.e..... �' IL.I�f .�................. w� .._._..... . ........................................... ........... ..................................... (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 County Ordinances, State Laws, and Rules and Regulations`of the San Joaquin Local Health District. Horne owner or�licen- sed agents signature certifies the following: • "I certify that in the performance of the work for which this permit is Issyed, I shall not employ any person In such manner as to be esu ec Workma 's Co ensation ws of California." ' F I, Signed .+.--........ dxs,0__......___-• By ------------------- ...- Title . mac.? :._ (if other than awned ;,• �EDEP _RTMENT USE ONLY " APPLICATION ACCEPTED BY0.0 !' f:_ ff BUILDING PERMIT ISSUED .............'_ DATE r� to ..��~....: ADDITIONAL COMMENTS -••-•• ----------------------•. .DATE { ........................•.--•----- ..... ........ ... ............_... ........................................ ................................. ..................................•......................... ............................................................ ........ ..................... .. .. -�---- ......__..........__...._....................._..-----.......---•--........---- ........._ ................... Finan Inspection by --_ ,- .. _ .. ... _ .--• ............................................... .....Date SAN: JOAQUIN LOCAL HEALTH DISTRICT E_W 13 24