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FOR OFFICt USE: APPLICATION FOR SANITATION PERMIT F Permit No. -Z-= 1 --------- ------------ -- -- ---------------- (Complete in Triplicate) �y----� ---" --- � Date Issued --1 -7---7-L - This Permit Expires 1 Year From 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO f �-1.---- -e-- CENSUS TRACT __________________________ ---- ---- ------------- --------- ,, / + Phone ------------------------------------ Owner's Name _ [ --- --------•----- -------------- -- = w -- `�` _ __. - -- - tY Ci ? Address r Contractor's Name ., -Eco-License # Phone Installation will serve: - Residence Apartment House❑ Commercial []Trailer Court Motel ❑Other -------------------------------------------- Number of living units:---- Number of bedrooms ____2--'..Garba4e Grinder ____--__.__ Lot Slze-_------------------------------- ------•---- --------Private Private ( Water Supply: Public System and name -------------------------------------------------------- ----------------------- ----------- ------- - Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .�k Clay Loam.0 li 4 Hardpan F1Adobe F1 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.) *4IN NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 2t?Q feet,) C\` PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-------------------•----------------= ------ Liquid Depth ------------------•------- Capacity -- ----------- .-"- Type -------------------- Material---- No. Compartme is �. yp 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 CODI �[ ) p Water Table Depth -------------------- ------------Rock Size ----------------=--------------- Distance to nearest. Well --------------------------- ------------Foundation -------------------- Prop. Line -----_-----------•-- REPAIR/A _ ._ - - DDITION{Prey. Sanitation Permit.#�-------- --------------- ---------- - ---- Date --------------------------.-------) Septic Tank (Specify Requirements) ----:----- ---------------------------------- ------------------------------ #, _ --------------- - -------------------------- Dis al Field (Specify Requirements) -_-�� ---- - --- - - ------ - - ------------ -- . - } A----�` -. / __ --------------- (Draw existing and requited ad __ - - � -- -- ----- - "" clition on reve se 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 th`e,San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "b "I certify that in the performance of the work for which'thi.s permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------ --- �--------------- Owner ------------- Title - ----------- -- - ------------------ By ------ ------------------------------------ ------- (lf other than owner) ii FOR DEPARTMENT USE ONLY t - DATE y=/-?--7-)-APPLICATION ACCEPTED BY ------------�-- -- - -- - ----- ----------- ----------- - ------------- - BUILDINGPERMIT ISSUED ------------------------------------ ---------------------------------------DATE ------- --------------------------------- ' ADDITIONAL COMMENTS ------------------ ----------------------------------- ----------------------------------------------------------- -� �-r*�C------ -w'� ?' ¢ ------- - ---------- - ------ - ------------------------------------ ---- ---- Date - -- '� -- 7 ------{ Final Inspection by: SAN JOAQUIN LOCAL HEALTH DISTRICT r W 0 1-'AS Rev_ 5M