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t -UR OFFICE USE: - APPLICATION FOR SANITATION PERMIT lComplete in Triplicate) Permit No. •• This Permlt Expires f 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 mad a compliance h County Ordinance No. 544 and existing Rules and Reglatlons: JOB ADDRESS/LOCATION Owner's Name ............................. CENSUS TRACT i7. u ,7 � .. lfX"_ Phone c Address .l�iy?' �............... �. ......,.......... ....... ........ .... City :. Contractor's Name . License # t ! __ •Ez�•!.�-,:..---�..... Phone _ 3 Installation will serve: Residence Cn__Xlp�artment Housed Commercial ❑Traller Court ❑ Motel ❑ Other .. Water Number f living unit stem Number of bedrooms --, 3 ----.Garbage Grinder ............ Lot Size .................................. Supply: y and name :............Private Character of soil to a depth of 3 feet: Sand n Sift ❑ Clay 0 Peat C Sandy Loam ® Clay Loom ❑ Hardpan ❑ Adobe ❑ Fill Materlol ............ 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 f j SEPTIC TANK l Size -------------- ................................. . Liquid Depth ........................... .� Capacity ..... - Type ----- -------- Material .-_--_---..._..-__ No. Compartments ... J ................... Distance. to nearest: Wel!------ ....... -....._-- , .... _•...Foundation ...................... Prop. Line ...................... 6 LEACHING LINE [ J No. of Lines ------------------------ Length of eachline�--..._._...... ...... ....... Total Length 'D' Box ........... Type Filter Material ........----------- .Filter Material ............................. Distance to nearest: Well ........................ Foundation ...._.................. Property Line .... ........ ............ SEEPAGE PET [ ] Depth ----- ----- - - ----: Diameter ---_---•-••.•_-- Number ..�_........_.............. Rack Filled Yes Q No ❑ Water Table Depth..................S .........•--•--•.•.•...--..... Rock Size .....---------- Distance - ---- --Distance to nearest: Well ........................ ...........•.• .Foundation C .................... Prop. Line ..........---•-•... _.. Ip REPAIR/ADDITION-(Prey. Sanitation. Permit +# -.----- -------.------ .......... Date ............ Septic Tank {Specify Requirements) ........-------- I......................... Disposal Field (Specify Requirements) ........--- --------------- Q_. `.1....... �_c7�� c --_---- ----•-------•---------------•--................. ------------- raw existing and required addition on reverse sidel ......................................... I 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. Rome 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 sub ect 41oWkman's Compensation laws of California." Signet# ------ ............... -••-- ...._..... Owner / (If other than owner) (.`1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _...--`..d3 _ DATE BUILDING PERMIT ISSUED .... ................. .................... HATE....----..............._.......... .... ADDITIONAL COMMENTS .......................................... ....._..._._...........................•- . - .................................................•-•-. .•-••..............•-------........_-..-----..:_........... ............ Final Inspection b •-----•. ..... . .. .........• P Y . .............:....... t;✓i•f 13 2h 1-�6 tl i�v, 5M -.................................................... gate �.3/.�� -- - AN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3k1