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-FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ._._. . .. _.................. Permit No. .A.....Z._...x..../...... (Complete in Triplicate) . .. . ........................................... err 7.7 This Permit Expires 1 Year From Date Issued Date Issued .,1........:....... 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 Reguiatlons: JOB ADDRESS/LOCATION ,^_,cSZ.Jfngp..f...�t............................................................CENSUS TRACT .......................... Owner's Name •. :.. . t t..................................................„........I...... Phone.P'3S1`1,!l............... .............. ......... .... . Address ..i��`s. .. .:.. . .. City .. 110, ......................................._....... Contractor's Nome........ .. License# ........................ Phone ............................. Installation will serve: Residence gApartment House o Commercial ❑Traller Court a Motel❑O?her.....22...................................... Number of living units,...l....... Number of bedrooms ..•.......Garbage Grinppd,er, ............ Lot Size ............... Water Supply: Public System and name ........................................................._.�"Y° ..................................Private${ Charocter of sail too depth of 3 feet: Sand[] Silt❑ Clay jg Peat❑ Sandy Loam ❑ Clay loam❑ Hardpan❑ Adobe ❑ FIII Material............If yes,type............................. i (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION, (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( ) SEPTIC TANK ) Size................................................ Liquid Depth .......................... Capacity 1a: - TypeQr.$roP.•� Material.. �i.. No. Compartments ...C�..�.„............. � /1.... , ISO.'01 ao Distance to nearest: Well ...) .... ....................founpdation ..��'?.............. Prop. Lina�1.. ..... ......_. f, LEACHING LINE ( ] No. of Lines ....3............... Length of each line........(.a............... Total Length .... ✓ ( Da ......... ri D' Box ............ Type Filter Marla ..� .., epth Filter Material ......I�....................7...._..... if) Distance to nearest: Well . .+.......... Foundutlon ,,�d............... Property Line ..! .........„... SEEPAGE PIT ( J Depth .................... Diameter ................ Number ....... .................... Rack Filled Yes ❑ No C3 • Water Table Depth ................................................Rock Size ................................ /( Distance to nearest: Well ........................................Foundation .................... Prop. Line .........„........„. REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ..................................I SepticTank (Specify Requirements) ................................................................_.........._............................_............._..............- DisposalField (Specify Requirements) ..................................................................................................................................... ................................................................................................................................................................................_........................ ......................................... ..... ................................................_............................................................................................ (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accordance with S.+n Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District.Home owner or iicen• sed agents signature certifies the followdng: "I certify that in the performance of tho work for which this permit Is issued, I shall not employ any person In such manner as to become tubblaart toworrJ��•�[yxn's Compensation laws of California.” Signed ..............4-............... .....!..:..' '�.'......................................... Owner By..... .. . ............................... . . . .... ............................................. Title ........................................................................ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY...... ... ........................................................................ DATE ....... .. .J.s ................. BUILDINGPERMIT ISSUED..... ...................................................._.......................................DATE.......................................... ADDITIONALCOMMENTS..............................................................._._........................................................................................... ....................................................................................................................................................................................................„.... .................................................. ........................................................................................................................ ................................. ................................ ..... ... ............................................. .. . Final Inspection by: .V._x. ..... . . ... .. ............ . . . . ......Data. . .-........................... .. . ........: .... ....I.. ....... . .. ...S.A.N...JOP.•QU..N..LO.CA.L..H.E.A.LT.H...DISTRICT..... 13 24 7/72 3 X E.H. 1=68 Rev. SM