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F6RrOFFICE USE: APPLICATION FOR SANITATION PERMIT ................................................ .... (Complete in Triplicate) Permit Na. .................................... ....................,...._..... This Permit Expires 1 Year From Date Issued Date lssued .JF..a?K.".7y, 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. 5 4 and existing Rubs and Regulations: JOB ADDRESS/LOCA ON ..f`�... -..�"~'. .. ------. .. .J_ y� TRACT .......................... Owner's Name E- p _ .............................................. 1 � ss��ll ee�� (j- �7 ..._Phone ..Q�?4?-..._.,✓1�...l.: SM Address _... .�_.-.J. City f �( ,, f �2 _ Contractor's Name .� 'I C.�.f"�"i.' - .... .....0 ---- ---------------•-•-----.License Phone Installation will serve: ResidenceX-Apartment House,❑ Commercial []Trailer Court 0 Motel0 Other ......... ................................. Number of living units:..... .... . Number o edrooms1!3_._.__Garbage Grinder ............ Lot Size ............._._.._ .__._.-_..._____.... Water Supply: Public System and name .--• ( .K l_ _ C? (A.............................. .................................. vote Character of soil to a depth of 3 feet: Sand ❑ 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,j PACKAGE TREATMENT [ ] SEPTIC TANK f Size---------------- ...._............. .... Liquid Depth ----- ._._....._ ......... Capacity .. . Type ------- ------------ Material..._. ------- No. Compartments -----.--........_.._.. 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 ._ .... .............. Rock Filled Yes ❑ No ❑ Water Table Depth ............................................._._Rock Size ....................------------ Distance to nearest: Well -----------------------------------------Foundation .............. Prop. Line ---- REPAIR/ADDITION(Prev. Sanitation Permit# ......................... .................. Date ._.------------------------------- ) Septic Tank (Specify Requirements) -------------- ----------------- • ---------........ -------- ..._................_._.......................... Di s 0a F' Id (Specify Requirements) ... ._....-•....................... -- ........... ........._ - -.._ _.....................::::.... -� (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 C pensation ws of lifornia." . .... ' Signed ... ,„� .. ��--J�- --- - � �... ------- Owner BY .............. --------- ...... Title ... i........... . ... . .......................... � (If other than owner) FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ._.._... ��._ .---...- ....._._.._. DATE . d.-7 ------------ BUILDING PERMIT ISSUED ...................... DATE . ...., ADDITIONAL COMMENTS ....... • ..... ..------.... - ........------------------------......... ...------..-•--•-•--- ---•= --------------------------- Final Inspection by: -_-------------- ---- ------_----- ----------.....Date .... ...... r_...__ '< SAN JOAQUIN LOCAL HEALTH DISTRICT 1 2