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FOR OFFICE USE: .. APPLICATION FOR SANITATION PERMIT R (Complete In Triplicate) Permit No. . .._._.. .. ' ...........................:..............:.............. . This Perratft Expires f Year From Date Issued Date Issued . 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/LOCATION'` ......CENSUS TRACT -1 Owner's N 1/- L T�- . -Q....�.YC�.s .g.�!j7-1J. .... :................ .......... Phone Address / fie' �f /. /�/ rG'G9 . -.. ....--•--...-•---.-••-•....... City -_...._ _.. ��Contractor's Name ---•-•-.----...Cl license .. Phone e.�.�?�... 'f..- Installation will serve: Residence I]Apartment House[] Commercial ❑Trailer Court 0 I Motel ❑Other............................................ Number of living units:........:. Number of bedrooms � Garbage Grinder lot Size Wafer Supply: Public System and name -..:- Private [ - - .................... ; Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ 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 .pi rm d if public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC T ] 5�� e........ .......... Liquid Depth Capacity Type ........ Maters ... o. Compartments ---------- Distance to nearest: Well ___.Foundation ... Prop. Lina _3 LEACHING LINE [ ] No. of Lines -.._--.--- ---------- Le gth of ea line.................... ...._" Total Length 'D' Box ------------ Type Filter M terial .....:.. ..........Depth .Fitt Material I ....... Distance to nearest: Well ... ........... oundation ...... ................ Property Line ........................ SEEPAGE PIT O Depth ------_------------ Diam ter ------------ --- Number .----- .___....... _..... Rock Filled Yes ❑ No ❑ Water Table Depth ------:= -•................. ...................Rock,,Sixe ................................ Distance to nearest: Wel .................. .............:.......Foundation .................... Prop. Line ...................... RLPAIR/ADDITION(Prev. Sanitation Permit# -=-•---.-••--____-• ----- ---_--•____-- ----••-----�� ;_ '. Date --------------_--------- Septic ------ - ---___-. Se tic Tank (Sp cify Requirements) __-.. _... . ...---------- Disposal Field {Spe _y Requirements) r . .. -1 3 y --- {Draw existing and required/addition on reverse -idf.. 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. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which thisermit is Issued I shall not employ p p y an y person in such inner as to become subject to Workman's Compensation laws of California." Signed - ` ----�� - -- --�---- Owner BY ----- ------ - .. - - ....Of other than owner}r) .-----•---- ----------•------------- -T ---- Title .... -...--- .--- .. . ---•---. .................... ... FOR DEPARTMENTVSE ONLY APPLICATION ACCEPTED BY -------- - Or ! :----•--•• - ..._ .... DATE ..�4-./:7.-77..... = BUILDING PERMIT ISSUED --------------. -----------.. _. ........DATE . ........................ ADDiTIONAV%COMMENT5 -------------------------------._ ----------- ------ -----------------••- = ....... �------------------------•----- -------_-------- - ---•----••----• - ----------------- ---------...----.............---..--.....-..... :. ----•-----,- !-- ---------------------•------••--- Final Inspection by: ..__... ------------- . ..... .......Date .. z. . .-..I .... ; EH ]3=l2L —6f3 Rev. SAN JOAQUIN LOC L HEALTH DISTRICT 8 # ' /7!� 3�i t•