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FOR OFFICE USE APPLICATION FOR SANITATION PERMIT (} (Cam'plot*in Triplicate Permit No. ��"��2 .. . . ..........I.........777�3_ ................................................... This Permit Expires I 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 compliaZw"th County Ordinance No. 549 and existing Rules and Regulationst JOB ADDRESS/LOA 1 N ... r ........ lt�Ga.._...._.........CENS S TRACT .......................... �. Owner's Name _.. `_' _ ... Address '/ `� _...._.... City J ----•-. r Contractor's Name ------ Y ---------------License #,V 71c- Phone Installation will serve: Residence❑Apartment House Commercial❑Trailer Court Motel J9 Other ---------------_--_- ..... f Number of living units_____________ Number of bedro ms ----......_-Garbage Grinder .----------- Lot Size .......... Water Supply: Public System and name ......-- :..___,o�_ _ ---- _ -------------•---------------Private ❑ Character of soil too depth of 3 fest: Sand Sil# Cla I P ❑ ❑ y ❑ Peat❑ Sandy Loam ❑ Clay foam ❑ Hardpan ❑ Adobe P Fill Material ............ if yes,type ............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be planed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT SEPTIC TANK Size.... r� ] fa) V �....................... Liquid Depth ?. ....... ) Capaci#yC -Type ARj-L Material...01-_ . _4_ No. Compartments A................. Distance to nearest: Well �.`_ ..............Foundation ....1_0.i___...... Prop. Line ------...go g LEACHING LINE [ I No. of Lines0- Length of each line..... ............ Total Length .176............. 'D' Box ....I__ Type Filter Moterials� h.aDepth Filter Material ...... ....I......................... Distance to nearest: Well QJ Foundation ..)?cC ............ Property Line ...I fir............. SEEPAGE PIT ( ] Depth ._ _ ....__... Diameter -__-`_ 3 . Number .............r7'L----------- Rock Filled Yes (Q No r Water Table Depth ............ -�� .--Rock Size --------- ?............... . Distance to nearest: Well .. b_-_W.&Aj....................Foundation _� .----•... Prop. Line ......� �► REPAIR ADDITION(Frau. Sanitation Permit# ................•---------------------_-._.. Date ..............-----------------_-_) . SepticTank (Specify Requirements) -•------------- --------•--- ................_-...................._................................. ......................... Disposal Field (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 accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licew sed agents signature certifies the fallowing: "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 subject to Workman's Compensation laws of California." Signed . --- --- - - ---- - -- - --•--- -------- --------------------------- Owner By ------ Title . (If other than ow ed FOJL DEP ARTMENT USE ONLY APPLICATION ACCEPTED BY . ... �- -- . ...... .......• DATE .--- BUILDING PERMIT ISSUED -----•----•--- ------- --- -_---DATE _.... --------------•----------._.._.---- ADDITIONAL COMMENTS ---------------•-------- _-- d f d :_::- SY:: . :.:::::.::::::: ------- - - --•--•-- ........ -------- ------final Inspection by: .__... - - �-----•-----....._.Date ._.. _.. 7._. .7 EH 13 2h 1-68 Rev. 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M I