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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -- .:_/.. (Complete in Triplicate) Permit No. ....7Y . This Permit Expires 1 Year From Date issued Date Issued ..........I-- .....-....:......:. 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 unty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . _7......_.- ..................... .... ........ ...............CENSUS TRACT .......................... Fac?- Owner's Name ........ ..��.. .... .... ,....... :. :. hone .. . . P City ...__.I... Address .. d. _.......�r ._.... _... ' Contractor's Name ....................... ...License # p -3X.?�Iihone .............................. Installation will serve: Residence Apartment House,❑ Commercial {]Traller Court ] 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❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -Eg-' Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material _-.......... If yes,type ............................ 1, (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) f NEW INSTALLATION. (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK i ) Size................................................ Liquid Depth .......................... ; CapacityType ......... 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 [ j Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No ❑ Water Table Depth ..Rock Size Distance to nearest: Well •.......................................Foundation .................... Prop. Line ................... ` REPAIR/ADDITION(Prev. Sanitation Permit ti# --•------•.................................: Date .......................... SepticTank (Specify Requirements) ........................................... ....................................-----•---.....----......�-..--•--------------------- Disposal Field (Specify Requirements( . ' ..:,r�'�' d�... �-- -- -_---- - -• ......... --•-------- ..............--------------------------................... --•------ _.._.... ...... ----- ----------- ----------------------- _..............................................._.._............I........................ (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 sti li not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------------------------- --- Owner 13y .._._.............................. /? '...- � . Title �mrt 'z ti -- ............. ............................... (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..,e .. _ -------------••-•---............................_....... ..., DATE ..__4. --� ...... BUILDINGPERMIT ISSUED ...................................................................................-----....:..............DATE ........................I.................. ADDITIONALCOMMENTS ................. ...................... --•-•----••--•------•-•--- -------------......................................................................... --------------- ----------------------••-- .........._.._.._...-•------------------------••---------•---...........--•--......------ .................. ...... ••--•-• ..........................................................................._ ...._ Final Inspection by Data J.'. . ------. -- ----•.. . . .. ............................ ---••---..... ............ ` SAN JOAQUIN LOCAL HEALTH DISTRICT / .. 1 3 9l. , I. �.. 7/79 1 M