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(. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............................................ (Complete In Triplicate) Permit No. 7 3 ......................................................... This Permit Expires t Year from Dote Ismed a . Date Issued . : :7 7 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 ...� -�k_.....W...... • • _ - CENSUS TRACT .......................... Owner's Name .......-/,�-•f .....................•.................---•----. ..... ----•...........Phone .............-.............<......'. Address ................/� ,,X.. .................... ..__. .._-�n7 - ---- -•�---..__.._.. City ...-------•--..._.... ....Contractor's Name ---• - ..• . .............License # ..1i �. .?-Phone •------ ....... -------------- Installation will serve: Residence Eq-A"'partment House❑ Commercial❑Trailer Court Motel ❑Other..------•------------------- ................ Number of living units:----- ___-- Number of bedrooms ......_Garbage Grinder ._.......... Lot Size ......j..,...,.,.._.._ Water Supply: Public System and name _.....-----•---•...--•••-•--•._...._....................._........ .........._,......_,......-- ...----...Private �r Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loan( lay Loam Q Hardpan p Adobe 0 Fill Material ... . .....if yes,typo...._......... ........ . (Plot pion, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse slde.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT f ] SEPTIC TANK f } Size................................................ Liquid Depth .................... Capacity ....._--•--- ....... Type ...................• Material...................... No. Compartments ,,:,.................. � Distance to nearest: Well ..Foundation .. Prop. Line LEACHING LINE No. of Lines --------- Length of each line.................. . Total Length ._........_..__ ............. 'D' Box ......_.._ Type Filter Material ....................Depth falter Material ....... ...... . ........----------. ---...... .a Distance to nearest: Well ........................ Foundation ........................ Property Line .._..................__. SEEP, IT [ J Depth Diameter . Number ............................ Rock Filled Yes ❑ No ❑ Water Table Depth ........................•.......................Rock Size ............................ Distance to nearest: Well ........................................Foundation .................... Prop. Line�•............................. ...................... REPAIR/ADDITION(Prev. Sanitation Permit# .......,._._..I............................. Date ................................... Septic Tank (Specify Requirements) ................... . _..._............_......._............._................. Disposal Field (Specify i Re urements .tet.. Requirements) ..� ............y- --------- .. ------- --•- - - ------------- --- (Draw H existing and required odditian on reverse side} I hereby certify that 1 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 licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit Is issued, I shalt not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -------•-•--- ................... - Owner By ......... ............... -• .'�t.. ... .__........... - . Title _. '� i+-(e -- (If other than owner} OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE . .. ... - .. ..�..................: BUILDING PERMIT ISSUED ---------------------- -------- -------•---------------- - ......................................................DATE -- ------------ .......................... ADDITIONAL COMMENTS _... ---------------•---------•-•--------•.._...----••------.......------•-------•-•------.,...__._..I.....••••...__...__.._..... -----------------------............... _------------6...................... ....................... ....................-1-1--------------- ...... ----- ---- - ------------ --- ----- -- ---- --- -- - Final inspection by: . . .............Date . ... .............._....._ EH 13 2L 1-6h Rev. SAN JOAQLIIN LOCAL HEALTH DISTRICT 8/7h 3M