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NOW _"0101 FI FOR OFFICE USE: OR OFFICE USE: APPLICATION FOR SANITATION PERMIT — 3�3 Permit No. (Complete in Triplicate) DateIssued.-Issued.- a S .7 _ ................. ............. ..-... . 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 described. This application is made in compliance with County Ordir:ince No.549 and existing Rules and Regulations: • - �,/� `� �. �i1� �� `� ...CENSUS TRACT..........................•----- J JOB ADDRESS/LOCA ION �� J ` . /� ly�/ �.. ... ��c _ ._ _.. . Phone ...................... Owner's Name yy.�+ (�_ / j�t-E ...�/ . . . . _ City r!�L��.r.�.. �"-- .ZIp...LS.%1.� Address . . . ..... one license # i.-. ............................ Contractor's Name Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other .. . ... - _ ... / . ...... ........ ............... Number of living units:. ..._ .....Number of bedrooms.... .-... Garbage Grinder ... Lot Size . . .... " s Public System and name. - .. I . ... . .................... Private Water Supply: y _ _.. .. Character of soil to n depth of 3 feet: Sand ❑ Silt❑ Clay F7, Peat❑ Sandy Loom Clay Loam. ...... . C Hardpan❑ Adobe❑ Fill Material If yes,type (Piot plan, showing size of lot, location of system in relation to wells,buildings,etc.must be placed on reverse side.) N�S `' h NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Size. .. . ...... .........Liquid Depth ... .........._..........� . .. ....... PACKAGE TREATMENT � ) SEPTIC TANK .. .. No. Compartments....... .. ... . . ...... Capacity _ Type. .... ... . ..... Material _ -...... Distance to nearest; Well . - " "• ...Foundation .. . ................. Prop. Line. ... .................... . ... ............ .. . ... . No. of Lines . .. .._ _ _ . Length of each line . .. .. .. Total Length ............................ -•---••- .. LEACHING LINE ( 1 'D' Box Type Filter Material.._ . ........ Depth Filter Material.............. ... . .................. ........................... ..... .._- .. _ Distance to nearest: Well .. .... ....... . Foundation ...... ... .... _... ..Property Line ........._ .... ..... Depth _- .. - .....Diameter Number.. __ ...-... Rock Filled Yes❑ No SEEPAGE PIT I ) P Water Table Depth....... ........... ..Rock Size........... ...... .......... ................... .. ..-. ....._ . \, Distance to nearest: Well. _. ........ ......Foundation... ................ ...Prop. Line..... ..................... 'U REPAIR/ADDITION (Prev. Sanitation Permit .......Date _ _.. .._ ....... ... .... .) .. ...... ....`. .. ....-.. Septic Tonk. (Specify Requirements) .- .. .. . .. -- : ents) Disposal Field (Specify Requirem ................... . ... ....................... .................... - _.. ....- __......... ......-.. .................... .... ........... . (Drcv.•existing and required addition on reverse side! I hereby certify thot 1 have prepared this application and that the work will be done in accordance with San Joaquin Courty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed 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 subiect to Workman's Compensation laws.of California." -Owner SignedG_ti- ,-c. -TitleBy_ (If ether than owner) FOR DEPARTMENT USE ONLY __— ___--_—_— �j DATE APPLICATION ACCEPTED BY _T �/� -- DATE _ DIVISION OF LAND NUMBER ADDITIONAL COMMENTS Date - - Final Inspection by: / F&S 21677 RCV.7/76 2M /- SAN JOAC,iUIN LV•C AL HEALTH DISTRICT cN la 2< i 1 " t 3 D