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,.% FOR`OFFICE"USf:•- z , APPLICATION FOR SANITATION PERMIT ..__.. (Complete In Triplicate) Permit No. ..................... ..................................... .... This Permit Exisims 1 Year From Date Issued Date Isst t-: _`�3.... 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 made in compliance with C my Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .....�-`�78d---- 6 a - . .........................................................CENSUS TRACT Owner's Name ..7T laA5 20 ..... h' .. ........... ........................ / O ....................... �...._. .............Phone Address -../.a�. - _.,.._ .................." City .��`T��/.fes /,� .._.. Contractor's Name - --�---Sr`/�/2 /. ......................... .. .. _..y•• 4----- ....License # ...... Phone � 3 b�1e Installation will serve: Residence KApartment House❑ Commercial❑Trailer Court 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 5iit ❑ Cla Y ❑ Peat❑ 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.) NEW INSTALLATION: 1No septic tonic or seepage pit permitted if public sewer Is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK I J Size---...:•....... ........................ ...... Liquid Depth ................. Capacity .......-------•..... Type --- Mat al.......•----------- -- No. Compartments Distance to nearest: Well --------------_ _____ Foundati .. Prop. Line ...................... LEACHING LINE [ J No. of Lines ------------ -------•---- Length of ch Uline._.---...._ _....---........ Total length 'D' Box --- Type .Filter Material .. .................Dep Filter Material Distance to nearest: Well ................ ....... Foundati ......................... Property Line ........................ SEEPAGE PIT [ ) Depth -------------------- Diameter .. ._..- ...... Numb r ..-------------------------- Rock Filled Yes ❑ No 0 Water Table Depth _------------ ....-........... •----- ......Rock Size ------...... ................... Distance to nearest: Well .... ................... Foundation .............. Prop.Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ------- --._-.---------• ------------- Date .......... ) Septic Tank (Specify Requirements) --------------- --- -•--------- Dispos Field (Specify I7equirementsl --------------- ---------- n/ -------------- (Draw existing and requi d addition on rev erse side) ------------------------................• I 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.DisMct. 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 _.._ . ---- -BY Owner - ------ -- -• . title _....__. Jif other than owner} A� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __ .-- - ... _ BUILDING PERMIT ISSUED ------------- DATE ...... .. ... ADDITIONAL COMMENTS ._.._..DATE -----------------...... ........_..._-_.___.._.-_---.__ _._._._..__._...____.__...-. _______________ _ _ _ ---_.___ .. ........................................................................ _. _.. Final Inspection by: ----- - --- --- 1................. EH ---...--•---.....-•-----------------------------..._...------........Date _.....----- .....--- 13 2 1-6v' 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7G 3M