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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT lComplete in Triplicate! Permit No. . ................................. This Permit Expires 1 Year from Date Issued Doti Issued . .... ...., Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describer!. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: w JOB ADDRESS/LOCATION -------- .............. ......................CENSUS TRACT Owner's Name ..._ ..... ................•..........,................... :. .......,..,...Phone ......... ,...... -_.. Address ... ........... , .. ...... ..�.... .rx� '......I...... ........... City ..... ..........., ......,...................................,............_. Contractor's Name .......................... ... � = License # . �- .�7 .a''. Phone .............................. Installation will serve: Residence®Apartment House❑ Commercial []Trailer Court Q Motel ❑Other ....................•--•-------•--------•-. Number of living units---------�. Number of bedrooms.-3_.--..Garbage Grinder ........:... Lot Size ............................................ s Water Supply: Public System and name .........:.... .............................•--:..:..._......... .......................__................Private Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam fl Clay Loom ❑ Hardpan Adobe ❑ Fill Material ............ if yes,type -A (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 see age pit permitted If public sewer is available within 200 feet,) . PACKAGE TREATMENT -SEPTI � . ........d � y Capacity -•---- Type Material.... _- No. Compartments .:.4.... .............. Distance to nearest: Well Xlp- ..FoundationJ.P .... Prop. Line LEACH#NGLINE [e No. of Lines .......ft3............. Length .of each line--------`g0.. ...... Total length ..1. °..lr`.......... 'D' Box ---1....... Type.Filter Material .... . ::.....Depth .Filter Material ............................................�1 Distance to nearest: Well .......IA. - Foundation [ ... Property Line ........ SEEPAGE PIT Depth _.. Diameter ... .. ..�.�. Number :...._..3................ Rock Filled . Yes No Q Water'Table Depth ---------11PQ--- ------=---------------Rock Size • ��.....1t: .it......... Distance to-nearest: Well _ ................Foundation .___� . ._: _... 7- ...--•--1-`�'°--� �r-- Prop. line ... .. .......... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --.................................. ) Septic Tank (Specify Requirements�. ----------------------------------------•--------•----•---•--------••- ......_..........._.-.......------........... ...... Disposal Field (Specify Requirements) ---------------- ------------------ ---•----- ...............................•---................................................ .. �-� r .. ............................. ---------------------------- ------- ---- .......................... ......._........-- ........................................ r (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. Horse owner or licen- sed agents-signature certifies the following: "I certify that in the performance of the work for which this permit Is issued, 1 shall not employ any person in such mannet as to become subject to Workman's Compensation laws of California." Signed =------------------ 11.---- ----------------....---- •---- Owner ( ` 4 a- _.- ), BY Title li (if other than owner) Fok DOARTMENT USE ONLY APPLICATION ACCEPTED BY -- .....1 --- -----. DATE 3.: _ --- ---- BUILDING PERMIT`ISSUED --------- ------- -• ----- .... .......... --- --..DATE ------------------ ---._...__ ...... ADDITIONAL COMMENTS --------- ----------------------------- ............. ---------------------.------ -------------- -•,-•------------- -...................... ....... ----------------------- -------------- ---------------- ......... ......... ----------------------------------------------------------- Inspectionby: _._- ------- - .......................................... ................................. ......Date - ....` t... . ....... EH } 3 2!a 1-68 Rev, 5M SAN JOAQUIN LOCAL HEALTH DISTRICT $/74 3M r