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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � Perm_ it No. -,`�.--��••-- (Complete in Triplicate) ............ .. ......... Date lssued This Permit Expires 1 Year From Date Issued ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein compliance with County Ordinance No. 549 and existing Rules and Regulations: described. This application is made m p / JOB ADDRESS/LOCATION 7 r -1. � ----- - ti �I ��` ....CENSUS%�RACT .................•--f-••- = Phone.. I 4�.�1....... Owner's Name�/�-..11_ -- --- .._..... Address lam' ..-.. ----- ------ City -1. .. . ...................... -......... License # ----- ---- Contractor's Name -. Phone _� -=-•-.....: Installation will serve: Residence�Apartment House Commercial ❑Trailer Court C] 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 C3 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK j ] Size------------ -------- .......... ..... Liquid Depth -------- ...-....--....� C Capacity _. Type -------- ...... Material--- •- -----•- No. Compartments ...................... Distance to nearest: Wel[ ---------_-----Foundation .....................- Prop. Line ------------------•-. LEACHING LINE ( ] No. of Lines ._ ..... Length of each line ......................... Total Length _...---.-_-------_-_-. -. --..Depth Filter Material ..... ..................-------- - 'D' Box ..... Type Filter Material ................ Distance to nearest: Well --------------------...- Foundation .... ................ Property line .-...............-...... SEEPAGE PIT [ Depth .. ......... Diameter --------------- Number ............... ......•---- Rock Filled Yes ❑ No I❑ Water Table Depth ------------------------------------------------Rock.Size ----- •--- --- --- Distance to nearest: Well ---------------- ..Foundation .........__........ Prop. Line _------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- -------- Date ............._--------_----------) Septic Tank (Specify Requirements) .... ........ -----------------• ---....-------- ........._.._.-._..,f. - ........_.. Disposal Field (Specify Requirements) --------�a-`-�--- - --- � -----`7---------- - - - ---------- ....---..._..--.- ---------- ------------------------ ...........-............ ......- ----•---...... . ........... •- ................... ..........--.-...-._............... - --........................ ..............I—........ ......... ........................ (Drdw 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 C mpens tion laws of California." ( Signed . ---------- Owner Title . ..-. :... ................ .............. .......... i (if other than owner) FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY . ... . i� ice.-... -..... DATE ......./ ... !---..... BUILDING PERMIT ISSUED ---------------- .-........:..-.. .._.. .....DATE .._. ADDITIONAL COMMENTS . J/�2G-7-. ..__.L •- :.- - -Ciao ..------••- ..................... rr1P� .c 4O, rB.�.o�lr/ $ aJfrP/�`�= J *•.'l-.L-Cd-I ,. -- v ..................... r --- - . - - � /.__...- .._ -DateFinal Inspection b SAN -- JOAQUIN LOCAL HEALTH DISTRICT 717,2 3 M