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FOR�OFFICE DSE: /f• �� [[ APPLICATION FOR SANITATION PIRMIT (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Date issued .. :. - 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. 519 and existing Rules and Regulations: JOB ADDRESS/LOCATION .../0_1,,,Z4 /...,_._a',C?......, T...../r.,®.............................CENSUS TRACT ...................:...... Owner's Name �� .._.� 1/�� ..................................................................................Phone fAg.7".f�..Z�� ..... Address ;S/ 1 .............. .. ............................................................ City � ... �. ..__.. ............... Contractor's Name ___ �, 1/. ..License `! Phone .. Installation will serve: Residence 10 Apartment House f] Commercial ❑Trailer Court ❑ Motel ❑Other............................................ Number of living units:.- .----- Number of bedrooms ---2 .....Garbage Grinder Lff7.... Lot Size .. S.X_J�..r.......... Water Supply: Public System and name .................. .............._.--..__......:...._....._ ...........................................Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat[] Sandy Loam [] Clay Loam 0 Hardpan 0 Adobe Fill Material ............ If yes,type ............... ............ �N (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 pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ J 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 .Filter Materials.......................:.................... � Distance to nearest: Well ........................ Foundation ............ '--- Property Line ........................ SEEPAGE PIT [ ] Depth .................... Diameter ..............__ Number ............................ Rock Filled Yes ❑ No 0 Water Table Depth ---------------------------.....................Rock Size ................;............ Distance to nearest: Well -----------..................-----------Foundation ----------- ... Prop. Line ..............,....... REPAIR/ADDITION{Prov. Sanitation Permit# ....•--------------------------------------- Date ••.. ..._..__--- .!_-_-----) Septic Tank (Specify Requirements) ---___..........................._.__...•• - Disposal Field (Specify Requirements!. --------- '.0 '��------...*01._. � °-----,T ----------•- ---- - ...........•.......................................................................... ._. T - !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, 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 laws of California." Signed ----- • ------- er th owner) FOR DEPARTMENT US NL / APPLICATION ACCEPTED BY ---------------- _ DATE .... -LG.-7�_ ........... ---- ---------- ------------ - --- -- ------ A. -- ---- I BUILDING PERMIT ISSUED ... ... ...... ..... .. . -- . ---....------------.DATE. .. --_-- ----------- ADDITIONAL COMMENTS --------------------•-.-------._....__-•- - -------------------------------------------------------- ---- ---- -------_------I-------------------------------------------- .............I..... -------- ------- ............---------------------------------------------------- -----------•---•----------- .............. FinalInspection by: -•-----------_-- Date ..... -J.7_`� EH { �3 � �� • + SAN JOAQUIN LOCAL HEALTH Di ICT 8/7h 3M