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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ICompletei>n Triplicate! Permit No. ..................._. --..........".......................................... wa This Permit Expires t Year From Date Issued Date Issued~.. /�. �7 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 mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: i JOB ADDRESS/LOCATION........v�. ��iw�� ............................ ......,.......CENSUS TRACY Owner's Name ...,_._ . ... r ......•.....,--•.............................. one .............. Address . . ...._._.._. ..._....... ....... City .. Contractor's Name ............. .... .......... ...........License .�.cY .��........ Phone ....-.:.........:............. Installation will serve: Residence&fAportment House 0 Commercial Mailer Court E] "'Motel.❑..Other................:. Number of living units•_...i< Number of bedrooms ___-�.Garba a Grinder ........::.. ....................... ................. F - Water Supply: Public System and name ------------- ..:........Private ' Character of soil to a depth of 3 feet: Sand -Silt[]� Gcy;Ql Peat❑ Sandy Loam Q Clay Loam ❑ Hardpan [' Adobe 0 Fill Material ............ If yes,type ................ ............ lPlot 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,[ PACKAGE TREATMENT ( ] SEPTIC YANK I Size..:.....:.:.....:........................:...... Liquid Depth .......... Material.....'..: ............ No. Compartments ...................... Distance to nearest: Well ----••-------•......................Foundation .......:............. Prop. Line ..................:... ' LEACHING LINE [ ] "No. of lines ------------------------ Length of each line------....................... Total Length ............................ 'D' Sox ------ Type filter Material ....................Depth .Filter Material ............................................ Distance to nearest: Well ........................ Foundation "..:.................... Property Line ................ SEEPAGE! PIT [ j Depth -------------------- Diameter ---.--- ..... Number ............................ Rock Filled Yes 0 No (], /Water Table Depth --------------------- ----------------------- -Rock Size ................................ Distance to nearest: Well ................................:.......foundation .................... 'Prop. Line ...................... REPAIRMI)DITION(Prev.'Sanitotion Permit# ..................:.......................... Date .................................. r Septic Yank #Specify Requirements) ...:............ .........._... - _.:......._...._... Disposal Field (Specify Requirementsl ..cz. s nx--- ............................... ................ -cr...... __.. t-.. - _...... ................ - �� - ........... raw existing and required addition on reverse sidel I :hereby certify that 1 have prepared this application and that the work will be done lin 'accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,Districit. Horne owner or Ilton• 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 manner as to become subject to Workman's Compensation laws of California." Signed------------- --------------= ........-_-•------------ Owner BY .. a .--- --------------" �--------------------- Title _.Ct .d-41x4'u.. ........ ................... (if other than owner! FOR DEPAR T USE ONLY APPLICATION ACCEPTED BY .__. l : .......:....DATE BUILDING"PERMIT ISSUED ------------ .................. -- -•- --- -------------------------------------DATE ---....................................... ADDITIOI14AL COMMENTS .-------- ---- ... ------•---...-•..........--------- -----------....--.------------------._._.......---...----....----•--_. ------- ----- ---- ---------- --- ------•-......_..----•-•.._._...--------._...--------------•-••--------••-"------------._.... ...-------- FinalInspection by: 1 ----- .... --•----•-•- ------- -------- ---- •-•---------•----.._.._-_..._.._.__. ... -- . .._Date -a_ " / -• 3 - .._ EH 13.22 1-68 Rev. ZM SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M I