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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ......... ....................................I......... (Complete in Triplicate) Permit No. _.7c` . ............... y This Permit Expires it Year From Date Issued Date Issued Application is hereby made to the Stan Joaquin Local Health District for a permit to construct and install the work herein' described. This application is made in compliance with Co�ty Ordinance No, 549 and existing Rules and Regulations: 1013 ADDRESS/LOCAT a�......... �._,._.. .1-----.9 ............__.:_...' ;.. .........CENSUS T RACT ..................... Owner's Name ....... ------ --------•--- _------ Phone :.... .. Address ...... ........ City `" t Contractor's Name ..:...... _ license # '7f,!__.._T. Phone ----- ...V.. - ?. l Installation will serve: Residence partment House 0 Commercial ❑Trailer Court �] Motel E]Other .......................... I Number of living units: .). ---- Number of brdrooms ... Garbage'Grinderr '...._.Lot Size _.. �-- t Water Supply: Public System and name .... ..... "•-- _ -----------.......... ..........Private ❑ Character of soil to a depth of 3 feet: Sand Silt❑ Clay eat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe Fiii MaterialIf yes, type ____________________________ {Plot plan, showing size of lot, location of. system in relation to- wells, buildings, etc: must be placed on reverse side.} NEW INSTALLATION: 4 m' . {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK i ] Size......................... ----�............ ... Liquid Depth ..----------•--•.......... Capacity ' r`� ..... .Material-----------...... No. Compartments ............... Distance to nearest: __..' Foundation Prop. Line ........ ---- -------------- _.,._.............. ... LEACHING LINE [ ] No'.'-,of Lines._..-................... Length of each line............................. Total length ............................ 'D' Brox T e Filter Material .Depth Filter Material ' distance to nearest: Well ........................ Foundation -_-----------......... Property Line ............ SEEPAGE PIT [ j Depth I-------------------- Diameter ...... Number ............................_ Rock Filled Yes ❑ No ❑ �" Water_Table.Depth ........Rock Size t Distance to nearest: Well "`� - ...�....-�.......-.......................Foundation -----:.............. Prop. Line _..-•--•-- ......... REPAIR/ADDITION.{Prev. Sanitation Permit°# .........._.._.---- •-•-_-•- '-�:Date .. ---•--------••--•-----------• ° Septic Tank ,lSpecify Requirements) ..__.:''....._..._..Gsir'...----. _--- - . .... .__ f__ Disposal Fiel (Specify Requirements)- .._.. .- - •--, j!(,1 - /_. - - .. ---------------- - /� 0-7, 'J----- _09"o - f%-11---------------------------- ---- ..._...---- -- lDraw existing and required additionaon 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." ' Signed . :............. ----••-----•... Owner # ; By ....... -- ........... ��1 - Title .ln Z ..... (if of r t n owner] ��. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ---------------------I............................. DATE .. .�zf 7r� ......... BUILD IN PERMIT ISSUED ......:..... ..........................- ------------ •--•DATE ....... ................................... ADDITIONAL COMMENTS ° • s .................•... .......... ........................................_...---............_................._.._..---••-............--__----------•--.-.... - -----•--.---- - •------.... :........................ ................. Final inspection by: ----_----_ ..........Date _ _ ; � ............... i - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.1.3 241-'68 Rev. 5M a 7/723.,4