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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ��_�3 {Complete in Triplicate) Permit No. ; ..........-.................................... This Permit Expires 1 Year From Date Issued 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 dinance No. 549 and existing Rules and Regulations: 10B ADDRESS/LOCA?nj .........CENSUS TRACT ;i .... - .... Owner's Name .............................. .. ....... Phone ................................. --- ... ........ ... -------. Address �J lS.. .......... .................... City . .. ... ..........:...............,----------- a.... ....... .--• ---- Contractor's Name ----------------------------------------------- ........................................License # Phone .&63ZZ.5.a7 s Installation will serve: Residence❑Apartment House Commercial❑Trailer Court 0 Motel p Other............................................ i Number of living"units:............ Number of bedrooms ..........-Garbage Grinder .-.......... Lot Size ............................................ , Water Supply: Public System and name -----------•.................................................-•---._..........................................Private ❑ Character of sail to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam ❑. Clay Loam D Hardpan Q Adobe-CEI'Fill Materlol ............ 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: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) i i PACKAGE TREATMENT [ ] SEPTIC TANK i ] Size—........... ....... ....... Liquid Depth .......................... I Capacity p tY ------------------•- Type ----------- Material....................... No. Compartments ...................... Distance to nearest: Well ------------------------------------Foundation ...................... Prop. Line ......................00 i LEACHING LINE [ j No. of Lines --------------- ........ length of each line--------------------------- Total Length .................I.......... 1. j 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ---------------------... Foundation -_...................... Property Line SEEPAGE PIT [ l Depth -------------------- Diameter ................ Number :--------------------------- Rock Filled Yes ❑ No 0 N Water Table Depth ------------------------------------------ -----Rock Size --.... ................... Distance to nearest: Well -----•..........................'........Foundation .-----------........ Prop. Line ..................... REPAIR/ADDITION(Prev. Sanitation Permit# ......................... Date ---•-..- ...--.-....--..�f--•.-} o ' U s Septic Tank {Specify Requirements) ------ DisposalField (Specify Requirementsl ------------------------------------------------------- ------------ .................................................I....... ------ ----------------------------------------- --------I--------------------------------------......................................................-•---........_......_.................. (Draw existing and required addition on reverse side] I hereby certify that 1 have prepared this application and that the work will be done In accordance with Son Joaquin County Ordinances, State Laws, and Ryles and Regulations of the San Joaquin Local Health;District. Home owner or ilcen- sed agents signature certifies the following: N certify that in the performance of the work for'which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed - --- -- ---------•---------------------.- Owner By .. ---- -- -- ..... Title ----- .- ------------- -- ------ If other than ner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE .,-9 "rL .7..7 .::._._._` BUILDING' PERMIT.ISSUED ----. ---- DATE __._......._-- ADDITIONAL COMMENTS ----- ---------------------------- --- - ------------ ----------------• --------------• - ---• --• - ----- - ----------------------- - - =-- -- - -------------------------•------•......._..... �/� Final Inspection by: ----.----•...............Date .EM . . . 13 241-613 v. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M