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FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT ................................• (Complete in Triplicate) Permit No. ................................. This Permit Expires I Year From Dot*Issued Date Issued-.-,,.....C.....0 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 Na. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT N .... CENSUS TRACT Owner's Name � ,F�f7. .............. ...... .................... ....... .Phone ...............................• -- Address . fir.------- -------- ..........................City .... ...................... _ Contractor's Name __--•• 1 - ��r� ,l. .......... .........License# �r . - Phonei. `. Installation will serve: Residence' Apartment House Commercial❑Troller Court 0 Motel 0-Other............................................... Number of living units:.../.... Number of bedrooms ......Garb'da Grinder/tf/ Lot Size aqe e kw _ . Water Supply: Public System and name ...Private Character of soil to a depth of 3 feet: Sand❑. Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loam ❑ Hardpan[J Adobe Nf FIII Material ............ If yes,type............... ............ (Plot plan, showing size of lot, 'location of system in relation to wells, buildings, etc. must be placed,on-reverse slde)�-,J NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) . PACKAGE TREATMENT j ] SEPTIC TANK ] Size................ .... J�;wLiquidt"'Dopth .............. 4 Capacity -------------------- Type --•------•-----_ material........... ='Y rNo. Compartments ...................... Distance.to nearest: Well .................................foundation ...................... Prop. Line_---------...___--_._ LEACHING LINE { j No. of Lines ........... =. ---Length of eachf ni e.-.......................... Total Length 'D' Box ............ Type filter Material .............. __......Depth filter Material w _ _ .................................... Distance to nearest: Weil ' Fccindation SEEPAGE PIT ( j 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),-f..... .......... ... _- --•--.-.....0.�•/----:.s..-..... --._ - jeci�_........... Disposal Field (Specify Requirements) ...... , ---------- ------�` e /f •.+r+ - ................... - ----------------------- ----------'----•--•••'--------------------..................................:....................................................... .. # '{Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this applicatlon 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. Name owner or Been- sed agents signature certifies the following: ; --- "I certify that in the performance'cf the work far which this permit is issued, i shall not employ any P non in such manner as to become subject to Workman's Compensation laws of California." ✓ ; Signed -------- ---•-- ------- ---- ----- = ----------------------------------------- Owner By ------------• '. ---------------------•-----------------.... Title •other than owner] r {r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- _ DATE .-.. �I –- -----..... BUILDING PERMIT ISSUED __...... - ._... --------- --------------- ------------------------------ --------DATE ............................ ADDITIONAL COMMENTS .......... -----•------------------ -••--•- ----- ------------------- -- --- ----------------- �. Final Inspection by -` _ Date ER 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT $/?I, 3M •1