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3 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ,.....::... .x/�� .-..r.- V... .. .... !"0 Permit No: .7. 3`S_ - . . (Complete in Triplicate) r ...I..-"' ......................................................... This Permit Expires 1 Year From Date Issued Date Issued:'.............. , :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. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION .._... .. -:. .,.._...i-.C�; . . ... ...................................................,.......CENSUS TRACT ......._ ............ yOwner's .N...a..m...e.......�.. ...�......�..V.L � . ................. ...................... ...... ...... .................... City ......... . ..........--------........................ . Contractor'sName" ,, a .,l- ............ .._--.- ...........................License # Shl� .�.. Phone Installation will,serve: Residence®Apartment House❑ Commercial 'OTrailer Coutt 0 l � Motel ❑Other ............................................ t Numberrof living units:...----';Number•of bedrooms .......Garbage Grinder ............ •Lot Sizer'. --(� ...........CJC� Water Supply: Public System and name ......-.................................................._.................•r•r••..............................Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt E] Clay ❑ .. Peat❑ Sandy Loam 0 . Clay Loam ❑ / Hardpan ❑ Adober) Fill Material ............ if yes,type ...........tl.......... �3 {Piot 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,) -t PACKAGE TREATMENT [ ] SEPTIC TANK ] Size................................................ Liquid Depth .................... -•- l .• s CapacityType ...... Material................... No. Compartments Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... A LEACHING LINE ( ] No. of Lines ........................ Length of each line.................. Total Length .-.......................... *J� 'D' Box ............ Type Filter Material ....................Depth Filter Material ... ........................................ Y Distance to nearest: Well ........................ Foundation .......................{ Property Line ........................ FF0AGE PITDe th-r!}....... _Diameter [ j p . ----•------ ---- Number ............................ Rock Filled Yes ❑ No Q ` Water Table Depth ................r...............................Rock Size Distance to nearest: Well ........ ....... ....Foundation .... Prop. Line REPAIR ADDITI Prev. Sanitation Permit# ... ..:...:................................ Date .................................. j Septic Tank (Specify Requirements) . . s _.................--•---. ....�...................... � . - Disposal Field (Specify Requirements) _r -- _.. ., --�f` -----------• .. ..... --- -:------- ..... .. . . ..... ......t.... ......... ............................................................. ...... ...........................•-•••-•-•--.....-•---......... 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 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .................................. . ..•- .......................... Owner ' �'� By ..-. .... ........................ --•- ........................-.. Title ..... -- --.. (if other than owner) '00R D TMENT USE ONLY APPLICATION ACCEPTED BY ....... --••----•.......................................... DATE ... .. y, ........... BUILDING?PERMIT ISSUEd .:...... .... ..... ....... ............--•-•...........................:......—DATE ...........:•:.::.........:::.:t........... ADDITIONALCOMMENTS ..... .... .. .... • ---- ... ---•--......-•-------------------•---------------..._...._........................:.... .. ....................................................................... --- - ---- -- --- .... .,..... .. •------• Final Inspection by: .......... ......... .... . ..... ...... .... .:.. .. Date ..fir: ........... SA J AQUiN HEAL DISTRICT e u 13 24 1_-,&n o_.. ra• 7179 '1 M