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FOR OFFICE USE; �� •••._•,•.' ----.. .•-•-.-.•-. APPLICATION FOR SANITATION PERMIT permit (Complete in Triplicate) � ��•--•�� `�� i Date Issued ..y" :.7:� 1I........... .......................... This Permit Expires ] Year From Date Issued i Applicationis 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: i I� c JOB"ADDRESS/LOCATION .._...� f .. 4`'"` _. CENSUS TRACT .......................... �' _. r ... -...�/ ................ hone .............. ..................... Owner s Name .._...... :... -t- : ........ ........: .1 ---� I h r Address ----------� ......., ' ...... ... . ................................ City . . ............................................... II -�•- Contractor's Name .........License # , Phone Instdilotion will serve: Residence[] Apartment House Commercial Traller Court ❑ Motel ❑Other ............ ..................*............. I Numbler of living units:. Number of grooms-- .Garbo Grinder .-- - Lot Size .... C... ...._...�__.....•.. ; Water Supply: Public System and name .... .. ! .....-._.( �� .....................................................Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ Hardpan ❑ Adobe 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 slde.$ ! E NEW INSTALLATION: (No septic tank or seepage pit permitted,if public sewer is available within 200 feet,) (s'................................ s' PACKAGE TREATMENT [ ] SEPTIC TANK( 1 S � ize....___.„•,•__.__•............................. Liquid Depth .......................... i I Capacity .................... Type .................... Material------------ ......... No. Compartments ......................� IDistance to nearest: Well ....................................Foundation ........._.....__...._ Prop, Line ....................N LEACHING LINE ' No. of Lines ......./............. Length of each line......a C7............: Total Length _. rl.. ..............L9 'D' Box .`7(5- Type Filter Material . .D4 1Aa.....Depth Filter Material ...... .......................:... , I� Distance to nearest: Well .M.::i..fCls'.f�:[ Foundation ... //1�.............. Property Line ..: ................. ..� SEEPAGE PIT [/ Depth .�$7r.....-_ Diameter �.�._ Number .._.....L.................. Rock Filled Yes Z No O I Water Table Depth C7a.........r Rock Size ..r �k Distance to nearest: Well ..._ e-4..........Foundation ... Prop. Line ..4............... Vy w REPAIR/ADDITION(Prey. Sanitation Permit# ..........•................................. Date .................................. Septic Tank (Specify Requirements) ...-••-•-•--•-.............- ---•• ..-- r. ............ . _............._ I J-, X Disposal Field (Specify Requirements) -------- d ...----- -•-- `` �-•.. �` �- -._ .._.._.... �M........... ......••• .................................... 1�- 4 4---...----------•----........-•--•-............_.._....----•-------. .................... ......_. 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 far 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." { i . Owner Signed ...... .... Title ---•----- By ...:.��. . i (if other than owner i' FOR DEPARTMENT, USE ONLY ' APPLICATION ACCEPTED BY .. _. DATE .. BUILDING PERMIT ISSUED .. ................DATE ADDITIONAL COMMENTS .................................. ...............................................................................................I................ ........... ........... ........................................................................................•••-•---..... . ................................----------............................••-•........... �M ............................... :...._._........._......._......_.........._...... . . 0.. ...... E Final Inspection by: ...... ..... . ............... .......... ate ` SAN JOAQUIN LOCAL HEALTH DISTRICT k .. 7 A 76 . .,.. ., 7179 3 M