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FOR OFFICE USE. Z�7 � Q Cp APPLICATION FOR SANITATION PERMIT g............... ........................................................ (Complete In Triplicate) Permit No............ l -- .. This Permit Expires i Year From Date issued Date Issued Application is hereby made to the Son 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: �QZS! S woc_F£" '' S - JOB ADDRESS/LO TION .,.��1. .., .1. .. .. Fn... �r (.........CENSUS TRACT ./q/- Z q-.4./ �J Owner's Nome 6`C.. ....... ....................................�.�.._�.�....._..... .......................Phone Address ...... .................. I..... ............ City . ................. Contractor's Name....................................................................................License # ........................ Phone .-............. .............. Installation will serve: Residence ❑ Apartment-Houseo Co ercial ❑Trailer Court 0 Number of living units:.......... Number of bedrooms .....Garbage Grinder 'L1177 -tot Size ....`.-...Anz.......... Water Supply: Public System and name ................................................... ....._...-.-------_-_------- Private �--- Character of soil to a depth of 3 feet: Sand 0 Silt ❑ Clay, ❑ Peat ❑ Sandy Loa Clay Loam ❑ Hardpan ❑ Adobe 0 Fill Material ........... If yes, type .......... ................. 3 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse tide.) NEW INSTALLATION: (No s ptic tank or seepage pit permitted if public sewer ' avollabe within 200 feet,) N PACKAGE TREATMENT ( SEPTIC TANK-[ J Size..J..................-.............. Liquid Depth ...........................tA ; i Capacity .. Type .. ............. Material.. No. Compartments ................... ; I Distance to nearest: Well 60 /O t -7 ......................Foundation ....... .'r.. Prop. line .......'`�...i` LEACHING LINE (] No. of Lines . .. 3. ... Length of each line'.... 'J. .............. Total Length .Z, Q............I 'D' Box b Type Filter Material ....................Depth Filter Material Distance to nearest: Well Foundation f../)_.rT..... Property Line �".._..-. SEEPAGE PIT [ J Depth . -'!!Z .... Diameter ................ Number ........... ............... Rock Filled Yes ❑ No Water Table Depth ... .... ........................................ Rock Size ...................... ------.. Distance to nearest: Well ..................:.....................Foundation ..... ......... Prop. line ..................... REPAIR/ADDITION (Prev. Sanitation Permit # ........ ....... Date ........... .... ...... ..--.........) SepticTank (Specify Requirements) .. .................................. ........ ....................... ...................................... .......... ....................... DisposalField (Specify Requirements).................................................................................................................................... .................................................................. ...................... ..... ..... _......... .......... .. (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 accordant* with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I c*rtify that in the performance of the work far which this permit is issued, I shall not employ any person in such manner as to becomes jecf to Workman's Compens tt n laws of California." Signed .:.. .. .... ..................... Owner By... . _........_.........................:................................................ Title . ... (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .....C.'........'......_..... /%............... . ......................... DATE .....%� `._... ............. BUILDING PERMIT ISSUED........................................................................ DATE ........................................... il�ADDITIONAL COMMENTS _...... .....:... ............... ........ .. p........................................................ .................................... -- ..,,.,,...............---.............................................................................. lf. ..................................�........,.................................---..................: :........: ......... ................ ... ............ ..... _... .. _ .... ...._.............L.................................. ............ Final Inspection by:.._ ..... - 1 1 :... ........... Date'.:: -'.7 ..................... SAN JOAQUIN LOCAL HEALTH DISTRICT - 7 /77 Q u