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FV7{ VrrR.0 VJL7 ...................I............................. APPLICATION FOR SANITATION PERMIT Permit No. .......................................... (Complete In Triplicate! „71:.$..7.. .. This Permit Expires i Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to constrict and Install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulatlonsi /J JOB ADDRESS/LOCA ��/,l .. ......... ... ..... .........................CENSUS TRACT .......................... ........ - ------------`---- Owner`s Name 1. ....... .......................................I............_.._.. :.. ........... .Phone .,? ,�.-�.... . Address 7��?.---- city .............. • - Contractor's Name .. ._ ......... ...............................license # c Z Z.�.s.7 Phone .W-5-!Y ........ installation will serve: Residencertment House❑ Commercial❑Trailer Court ❑ Motel ❑Other......... ----------__.................... Number of living units:---./:.. Number of bedrooms .......Garbage Grinder ............ Lot Size .. .1.. 1 ?s. ........:...... Water Supplys Public System and name ........................................................._......._..........................................Private Character of soil too depth of 3 feet: Sandr] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ day Laam ❑ Hardpan ❑ Adobe ` Fill Mcterlal ............If yes.type............... ............ Mlot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be plated an reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size................................................ Liquid Depth ........................ Capacity -----------_-•-_- Type .................... 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 ....................... . Ai SEEPAGE PIT [ ] Depth Diameter ................ Number ............................ Rock filled Yes ❑ No ❑'s Water Table Depth ..--•---•----•..................................Rock Size ................................ Distance to nearests Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prov. Sanitation Permit# .............................. . ........... Date .................................. j Septic Tank (Specify Requirements) .............. ..... .....-----................................... ....... ,. ....._...... �! Disposal Field (SPe Ify Requirements) __ ~.. ...__... ..�".�... -�' �.... . .. ...... ..:• *5-74L ---. �--�� ........................................... 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. Henn* 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 shall not employ any person in such manna as to be m st to Work n's Cognpensation laws of California." :,.anec+ . .... Owner V By ........................ . Title ...................... (If oche owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...- .... . -. . -A... ... DATE .� .-/ .' .e�.:-.- ................................................ BUILDINGPERMIT ISSUED ......................••--............. .............DATE>-...........----•-...............---....... ADDITIONALCOMMENTS ......... ....... . •----•. ...................------•-----------........_...----•-•-------•-------........ .............................----..............._. . ................ .. ------------....----- ---............---.............------... .............................................. .. . ................ ....--...........--..... ................. .............. f Final Inspection by. ------. .......Date ._...C... �.... Eli 13 211 1-68 11ov. �l SAN 30AQUIN LOCAL HEALTH DISTRICT 8/7h 3M