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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............. ...... .................................... �a7o Xomplete in Triplicate) Permit No. . ___.�-...-...... This Permit Expires 1 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 mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: '7 br 0 --A— iY tri y- 'F 9 JOB ADDRESS/LOCATION .:5.._ ...- ''.. :. " _ _- 5.- f'.....................CENSUS TRACT ...................-.:.... Owner's Name ....... ...........................................................•_--------.......:.... ........._......Phone ........ Address ` JR .. ... .. . . ................... City 1. ----j- .. _ Contractor's Nome � � �"'� ...license # .� � �' Phone .............................. �.. ---=------ Installation will serve: Residence ❑Apartment House❑ Commercial rrailer Court Motel ❑Other -------------------------------------------- Number of living units:............ Number of bedrooms ............Garbage Grinder .__. ....... Lot Size ................................ ........... Water Supply: Public System and name ..........................................................•----...--------..............---.............------Private i 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 ofsystem 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,) � �XS � i PACKAGE TREATMENT [ ] SEPTIC TANK� Size.Y �." �:-•.. ... ........... ....•----_--__ Liquid Depth .....�..............,__'� Capacity ..... Type G ....... Moterial_..C:�:..-....... No. Compartments _a.................� 0 Distance to nearest.• Well 1.0. o..�_.._._. Prop. Line ._....... . ..............Foundation -----�---- ......rte"•......... .._. O LEACHING LINE [ No. of Lines ....... .............. Length of each line----:--9.7 .-.__.......__ Total length ...�.�.................z 'D' Box _t=.._ Type Filter Material --4 2.. .. Depth Filter Material Zff... oo Distance to nearest: Well .-.!a p....._...... Foundation .--. -/-_P.=_'.:__.--:: Property Line ._._.��... ......... SEEPAGE PIT [ j Depth .--.--__- Diameter ................ Number ................--...-__.— Rock Filled i Yes ❑ No ❑ • Water Table Depth .Rock Size pF Distance to nearest: Well ..................................... Foundation --•-........ ....... Prop. Line -_----.---..__------ 0 REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. SepticTank (Specify Requirements) ----•.............._--...-------------------------------------...._........-•-----•-••------•-----................----.-.._.._---...._ Disposal Field (Specify Requirements) ------------- -------•--------------------..- .._.........._.....---------- .....................................................................................-..................... (Draw existing and required addition on reverse side) 1 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 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 subject to Workman's Compensation lows of California." Signed ............................................... .. --------------------------- Owner 8 Title ..Pic ---F ...._.. (if other than owner) FOR (DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y ... -----------------------•-------------------------- DATE ........... BUILDINGPERMIT ISSUED ...................••---•----........--------•-------------------.......-.-::..._.........._..............DATE .....__....._.:_......... ........... ADDITIONAL COMMENTS ........ ......-----•---'.............................••.............---------- ....................................... ............. .... ..........................................................-----------------------------------....................................,-----.... ......................................... Final Inspection b ..... -------..................................................Date /`:;r._-. ............. i SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H.13 24 1268 Rev. 5M 7(72 3 M