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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. . ............ . G-7T This Permit Expires I Year From Date Issued Date Issued . 1.._.__...... I...................................................... _ .,. �...,..._ I�D.S'--• Tho � 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: -2Y3Za - /v.. .frr � JOS ADDRESS/LOCA N �. .. --� _..;H.k�V -..�1... _.. ,,_ Owner's Name ...... ...... •- e .................................... S TRACT Address ------..6z1.1��. 79....._._. Ci �'�:..w...._.. on . .......................................•................. Contractor's Name .... ._ •-•-•• . _f-..... .: _... License # �?i :.. Phone .............................. F Installation will serve: Residence ❑ Apartmen use Commercial ❑Traller Court [] i i Motel Other ................ Number of living units_____________ Number of bedrooms ............Garbage Grinder ............ Lot Size ............................... Water Supply: Public System and name .. ..---•......_...._.____.•........................................••----......--------.Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay [] Pe'- at❑ 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.] f" ( NEW INSTALLATION: (No septic'I tank or seepage pit permitted if public sewer.is available within 200 feet,) J �. PACKAGE TREATMENT [ ] SEPTIC TANK-[ ] Size------------------------------------------------ Liquid Depth ......................... . Capacity + _--.- Material...................... No. Compartments ......_._-. •-•............. Type .......-..--- W I .......... Distance to nearest. Well ..Foundation ...................... Prop. Line ..... LEACHING LINE [ ] No. of Lines .-------•--: Length of each line.---.--•.................... Total Length ............................ 'D' Box Type Filter Material ...............:.....Depth Filter Material Distance to,nearest: Well ...... ...........:::... Foundation .............. Property Line --•-----••- ........... SEEPAGE PIT [ j Depth ..... :_..-•-.---•--- Diameter ....... ...... Rock Filled Yes [3 No :...::... Number .................... . Water .Table Depth .............................Rock Size Distance,tonearest: Well ........................................Foundation -----_. ....... Prop. Line ..._...._..._ ........ REPAIR/ADDITION(Prey: Sanitation Permit# ...................................._..._._ Date .............................. c Septic Tank (Specify Requi?ements) .................. ------------- • ........ .................. .... (� Disposal Field (Specify Requirements) .. .c- .. , . - �=;r,� - 1 p „ I ... .. % A (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 Son Joaquin County Ordinances, State1aws, 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 We an's Compensation laws'of California... Signed .......................... ........ .-- :,--- ...._ Owner BY .... .. .. .. ..rs . ( .... Title .. .._......__ ... l.`-1�.: (If other than owne . ,.1 } FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY............. a-:r- .._.......-.- DATE ._......_�..1! ..�f._•----- BUILDING PERMIT ISSUED __.._. --.- . ------------- DATE ........:_... ADDITIONAL COMMENTS ..........................•--•------•........_........ ................_.....................................................................................................----- ... ---•-•----"-•-••-•--- ................. ................................................................................................. ........... .. ........................................_:.......-- .... •---•-----:.._...-•---- ..............I....... ._...-- .. .... Final Inspection by: ......... .......................... --- ---- ............................Date .................. SAN JOAQUIN LOCAL' HEALTH DISTRICT E. H.13 241.'68 Rev. 5M 7179 'A r,s