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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT // r/ - .. ------ Permit No_ 77.�':��,a. (Complete in Triplicate) .............. !` ................ This Permit Expires 1 Year From Date issued Date Issued ...�1'� T i 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: j JOB ADDRESS/LOCATIONIV�'p_-• .. . ..----- - .-...CENSUS TRACT .......................... Owner's Nome ............ .. . . . .. .. .. .... .... ----------._,.__._......-.. ....................Phone ..._................................ i Address ........... ...$.D F , ........._. City �"" --- -- - ._ Contractor's Name .--. ...... ------.license # .1ff�_�J°. Phone .............................. Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court C1 Motel ❑Other .. ._ -- __ E Number of living units:.... .:...... Number of bedrooms _.7---ff____Garbage Grinder ............ Lot Size ..__.._ ... ............. ......... �, Water Supply: Public System and name ------------------------•-----------__--- --------------------.......---------------- ..... ------. ....Private Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ 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: lNo septic tank or seepage•pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK i ) Size--------------------------------................ Liquid Depth .......................... Capacity .- .. .... . Type -------- -------- Material-.----------.--.--. .. No. Compartments p - ----••----- - 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 [ ] Depth _... Diameter ---------------- Number ..---.:i ........-..,....... Rock Filled Yes ❑ No C Water Table Depth --•---..--•----------------------•...............Rock Size _...---------•---............... Distance to nearest: Well ----------------------------------------Foundation .... .......... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------f.._-.. Date ---.--------- ................ Septic Tank (Specify Requirements) ............. . ,.� -- - --- ---•----------- ----- rT—a Di osal Field (Specify Requirements) ... _ ti 7.. ....��--- -- ..... 6_4 ---- .• - --------------------- __- ------------ : _- ------------ - ----------------------------------------- .------ D raw ----.it- 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 San Joaquin i 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 .... ........................................... ----------- ----- - ---- Owner BY ......... Title ..�;.�Lat.J..... . ........... ..... ....... ................ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ._......( ,- - -------------- ------------ ---------------- --------•- -------------........... DATE ........ BUILDING PERMIT ISSUED ........................ .........—.......... ------------- .....DATE ADDITIONAL COMMENTS ................................... ------------------------------------ ---- �,/ Final Inspection by: --- ----------------------Date .- -. f / ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT a