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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............ .. .......... ............... . ... y ` .... (Complete in Triplicate) Permit No. -.... ...................... ................ ......... ..................................__....... this Permit Expires 1 Year From Date Issued Date Issued -..ef�.:�=.�_._. 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/LOCATION . /V-6 6 v- . . . 1 ,-- --• . •- .............. CENSUS TRACT .......................... Owner's Nome ... ...................... ..•------_-_Phone ................................... Address i 7. 4? . - � .. . .-.. - -------- -------- -- ---•--. City ...a .. . --- •- -------.....--•. ................................ Contractor's Name . --- License # .�� 3 Y Phone .............................. Installation will serve, Residence Apartment House❑ Commercial ❑Trailer Court ❑ Motel [-] Other ---- - ------- - -----------._.--....... Number of living units: . �... . Number of bedrooms ....a----Garbage Grinder . _... .. Lot Size ..-. � :� ............. •f Water Supply: Public System and name ................................................ .................. ---------.....,_... PrivateCharacter of soil to a depth of 3 feet: Sand❑ Silt C3Clay ElPeat[I /�Iay_L_o`a_m Sandy 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 side.) NEW INSTALLATION: INo septic tank or see ge pit permitted if p��ublic sewer is available within 200 feet,) , PACKAGE TREATMENT [ SEPTIC TANK-f Size.7/,, .. .._ �.��._ .�_-. . Liquid Depth Depth . ................. Capacity/CPOp 74Type r �..- Material.... -. No. Compartments ----2 -_._...__. Distance to nearest: Well 'r>a._`---------------Foundation ..... AP. "... Prop. Line _AF LINE No. of Lines .3. . Length of each line .. 50 ",.. . Total Length -..Z.' .°............. 'D' Box Type Filter Material ------- Filter Material -.- /_f.,��............ .... .. Distance to nearest: Well -.-....,�G-.�..._... Foundation Property Line .............. SEEPAGE PIT [ ] Depth . .._ . Diameter ................ Number . ............. Rock Filled Yes ❑ No ❑ Water Table Depth -- ..._.... ...................................Rock Size ..-•---------•------------------ Distance to nearest: Well .....................•------............Foundation ..... .... . ...... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ........ ... ........ ..................... Date --------.-------------------------) Septic Tank (Specify Requirements) ... .. .............. ........................................................- -..-..................... .... ............. Disposal f=ield (Specify Requirements) ----------------• ---------.............. . ... .. • - -- -----------......----- .---..-.... ...... _.... . ...... -• -........................................................ (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 Distrito. Home owner or licew 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 manner as to become subject to Workmar 's Compensation laws of California." Signed .... . ........ . . ... !J, Owner By . . . --------- i. .. - Title . ...... _ ...... (I€ other than owner) FOR DEPARTMENT USE ONLY ~ f APPLICATION ACCEPTED BY . - DATE T y - -•---------- BUILDING PERMIT ISSUED _ ..DATE . .............•...---............. ADDITIONAL COMMENTS .... ............ . .........----------- ..........................................•---....... ----•-•--- -- - -----...-----................ . . r��{ Final Inspection by: -- �G� Dot e. �./-.-f- , SAN JOAQUIN LOCAL HEALTH DISTRICT E•-H• L3 24 7172 3 , __--- ---- -1-'68_Rey. SM---- \I_ ---