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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT dye ................. ...:...........�.............. ----•... .7�_ . (Complete in Triplicate) Permit No. ........ ....................... /�� � .................... ............ ....... This Permit Expires 1 Year From Date Issued Dote Issued ............. .. 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 iirn compliance 1with County Ordinance No. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION .. ..A ��.._/!!r_1�WIr_��-' �"�d�� ......................CENSUS TRACT __...._..._._....--•..-••- Owner's Name .- .vy.... {r - .Phone .��1� ..— .... 1 .../ ------•-----.-----_ -•------•.-- ...... .. Address .... .. :.................../.. .. � ................._... City ..../--W/. --- --------._...----------------•--•--•.-------------- Contractor's Name .. Q . .... - ---_-------------- ------License # --- .....................--- Phone .............................. Installation will serve: Residencepartment House❑ Commercial ❑Trailer Court Motel ❑ Other .. . .......... ......................... Number of living units:.. _ ./. . Number of bedrooms .d __Garbage Grinder ......._.. . lot Size .. --------------� 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 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: (No septic tank or seepage pit permitted ifis se r is available within 200 feet,) (ft PACKAGE TREATMENT j ] SEPTIC TANK Size.--.. .............. ..... Liquid Depth .................... Capacity /M& .. Type P�"�- �t Mctterial_.�reC4 No. Compartments ...... .. ....._.. Distance to nearest: Well ...GUS. --.Foundation ....Ifl�------ Prop. Line _.__. .._ . LEACHING LINEX No. of Lines ... Length of each line ..._.+�� _---- Total Length _..,..1 'D' Box .. .� Type Filter Materia t4*A'_ Depth Filte M terial .j1 Distance to nearest: Well ..__../ Foundation ...... ..... Property Line _...... ..._. SEEPAGE PIT Depth I ' Diameter Number Rock Filled Yes No Water Table Depth ............... _--.---r-------Rock Size _. .:.. ...... . ......... Distance to nearest: Well .._.-.... .. !,/f ._..Foundation __.. ._ Prop. line . ...... REPAIR/ADDITION(Prev. Sanitation Permit# ........ ..........................__.._.. Date -----------------.._-------------.) Septic Tank (Specify Requirements) --•..... ..... ...... •- ......-------- ....._...,.............. Disposal Field (Specify Requirements) ------------- ------------------ .................................................. - •--............................ .._.... ----------- --- . .. ...I...........I.... -- ---.. . _ ...... -- .----- --....------ ---- --.. .................................. (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. Home owner or licen- 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 ject WorkM.. ' Co � satio laws of California." Signed _ ._. ------ Owner By . ....... Title (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . .. . ._ . r/ DATE .. ._�...7, BUILDING PERMIT ISSUED .. .. ._ .._ -- ------------- DATE . ._......_ ....... - ------- ADDITIONAL COMMENTS ------ - ----- ------------- ....---........... ............_....:---------- - ........... ..-... ....-..... ..................... ........................... ------------- ------------- ........ ------- .............. ' Final Inspection by: ---------------------- ----------------------------------------------------Date ........ ..��j�___.--_---... E SAN JOAQUIN ,LOCAL HEALTH DISTRICT r E. H. 13 24 l.'48 Rev. 5M - - 7/ 1x