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i FOR OFFICE USE: APPLICATION FOR SANITATION! PERMIT � ................................. Permit No: ...................... ...�.�.....__ . (Complete in Triplicate) _.......... ........................................... / - bate Issued .�.�............. ' ' ........._................... 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^Coulnty Ordinance No. 549 and existing Rules_and Regulations: M JOB ADDRESS/LOCATiON .. ..._��..,.zF�� ...,-._.... SST A Owner's Name ............ . :...P one . : Address --- ... . ...... ... ..... ....... .... City .... .. ._.. Contractor s Name ..-----_ . . ----- _ --.._ .License # Phone ... ...................... Installation will serve: . Residence [ Apartment House❑ Comm ercio Traiter Court 0 Motel ❑ Other Number of living units:__-_ ---- Number of bedrooms _,-?/.Garbage Grinder, .............Lot Size ._...........___ Water Supply: Public System and name ........ •••------- •. ---••-•....._---.............. --------•------ ....................:._.......Private (n�, -,zCharacter of soil to-a depth of 3 feet: Sand❑ Silt❑ Clay I-) Peat(] Sandy Loam lay Loam ❑ Hardpan ❑. Adobe_❑ Fill Material ............. if yes, type ----------------____________ (Plot plan, showing size of lot, location of system in relation .6 wells, buildings, etc. must.be placed' on.reverse side. i NEW INSTALLATION: (No septic tank or seepage pit permitted if p blic sewer is available within 200 feet,[ PACKAGE TREATMENT [ ] SEPTIC TANK Size...` .., .-:!__._ '__....--•--...... Liquid Depth ......................... v-. _ { . Capacity Lia. .... Type- _ Material----- No. Compartments .7.......... ./�Distame to nearest. s. ...............Foundation .....L_P .......... Prop. Line ...s�............. LEACHING LINE J Noof Lines Length of each Total• Length. . 'D' Box Typd Filter Material ...... -!�- Depth-Filter Material 1.1 � Distance to nearest: -Well ...... .�_._..... Foundation :...1..a.�..:...... Property Line ...r?............... + F SEEPAGE PIT [ .j Depth ..........., ___ Diameter ................ Number. - ...........Rock Filled Yes ❑ - No ❑ A' Water Table Depthi.... . . . Distance to'nearest: Well ___Foundation Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# .......................................... Date ..........:........................1 n SepticTank (Specify'Requirements) ................... ............. ....... ................................... ........................... .... ........-.............. Disposal Field (Specify Requirements) --••......................•-------...____............__._.__----_-----•-• ' -•--------=-- ------ ....r .. .. ......... . _----•.......:...... .......... 1 --•- ,.. ,......... o r_._._.._... ...-.; . ........... _._....... 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 Son Joaquin: County Ordinances, State Laws, and Rules and Regulations'of the San Joaquin Local Health District. home owner or lieenJ sed agents signature certifies the following: : - "I certify that in the performance of the work for which this permit is issued, I *hail not employ any person in such manner: as to become subject to Workman's.Compensation laws of California." Signed ............-------• -- --------------- •---_-•----.-.-.-.-.-.: Owner - ......_.......---- TitleBy . ........ ........ ....... (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .._ ...........:................................. ............._. DATE :./.C7..' .1....x..7. BUILDING PERMIT ISSUED ..............•----•..... -••••........................... -- --•_..... ---•••-•-•:...DATE' -••---.. ...................... - ..:.................... :. .......__...:........_..... .....------ . I ADDITIONAL COMMENTS ---------------.---._...... ...... , ........................................................__.................._._.._.......................................... - 4 k ........ ....:............................... ... .... 1 .r'.. , -- , Da . Final Inspection by - SAN JOAQUIN LOCAL HEALTH DISTRICT , � ryi, - - 7/723-M