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APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: - -- ------ (Complete in Triplicate) PermOR OFF�`U� � - -�� -- , Date lssued..1Q.::3.:7,_Y ----•• • ------------- --- -------- ----------- 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 Ordinance ��__.CENSUS Rd Regulations: I JOB ADDRESS/LOCA N. -.- - TRACT------------------ -- --- ....------. [P Owner's Name...._. -------- -------•----------------...----- ------ Phone. ----........-... --- c. Address-- o .......... city--------------�j-¢--'!! --- ZiP ------ ---- .-------. Contractor's Name... �� .........:License #3.._P..--.1----__Phone- !_.-. .7 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Itel ❑ Other-- -- - ....--- _------_-------------------- Number of living units:-......f-....._Number of bedrooms...1.....Garbage Grinder...-.--;---.Jot Size.__... --f '(�t-�; !------------- - -- -- Water Supply: Public System and name --------- --- - --------................. ........ - -....------------- .Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loa Hardanm - � p ❑ ..Adobe E]—Fill 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.- y- /r Liquid Depth..:.............. 1.Capacity./00-- -- Type. Matevial. j�-------'----No: Compartments-.--- - --_-------------------- Distance -_------- -----------Distance to nearest: Well----- �.74,0. - .-_ -._--.-.Foundation__ -- .Prop. Line----....... .._......... LEACHINGLength LINE No. of Lines Len th of each line------ Total Len th _� 'D' Box_ ._Tyl: Filter Materiel-- -.. "..,.Depth-Filter Material---- --------- --------------•---- -------- Distance,to nearest: Well-- .. -- ---...Foundation-- •--- -------Property Line.--------- --.------ SEEPAGE PIT [ ] Depth.-A.4 _....Diameter.... . Number Rock Filled Yes,4 No ❑ Water Table Depth................_--------- -- ----------------- ------Rock Size.._... - . . ......................... . Distance to nearest: Well--------------- .......Foundation - .. ...Prop. Line............-------.-.--.-- REPAIR/ADDITION (Prev, Sanitation Permit#---------•................... ... .............Date---------------- ---..................... --- -) Septic Tank (Specify Requirements)---- . ...... ................................. -- - ----------------- ----------- - ------ Disposal Field (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 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 subject to Workman's Compensation laws of California." j, J Signed--.. . ... .................. .. --- -:.Owner `- By......... �. L. Title ---------------------- -------- ------- (If other than owner) FOR DEPARTMENT USE ONLY .� .. ----....DATE . APPLICATION ACCEPTED BY....:........ /!�'3-'- DIVISION OF LAND NUMBER---------- ------------------ ------------- - __---- ----------T_ --------- --- -- - ADDITIONAL COMMENTS --------- ---- ..... ------------- --------------......--- .........--- .. ----- Date- .. JL....C�._- -- f + Final Inspection by:. . ........... _ J Fas 21677 aev. 7/7a 3nn EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT. �.