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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .........................:..........................::... w (Complete in Triplicate) v-••-_ _ Date Issued ................... This Permit Expires t Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein i described. This application is made in compliance with Coun y Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC TION ...4W,3 ..:/l... -..�.(,.l . ........... ......._.. .... ..............CENSUS TRACT ........... �`� - ........ ... :................Phone . .. .5..7 . Owner's Name _. . .__. Address .f,�, .•3.y....._. . . .._. ! ..........--•...... City .. ' Contractor's Name .. ...............License # a2?/...v��.�.1.. Phone • �.. .. .. �.S.a� r fi Installation will serve: Residence� partment Houseo Commercial❑Trailer Court 0 p Motel ❑Other ------- ------------------—............. Number of living units:------------ Number of bedrooms 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 ❑ F Hardpan ❑ . Adobe g Fill Material ............if yes,type ............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. crust be placed on reverse side.)' NEW INSTALLATION: (No septic tank or seepage pit .permitted if public sewer:is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK{ ) Size.......................................................... Liquid Depth ...................... CapacityType -------- Material-._....--------------- No. Compartments ....................... ! Distance to nearest: Well .................... ...............Foundation ........................Prop. Line ...................... l LEACHING LINE [ l No. of Lines ------------- ---- Length of each line---------------------------------- Total Length .............................. 'D' Box ............ Type Filter Material ....................Depth Filter Material ---.........................................� Distance to nearest: Well -•-•----------- Foundation ........................ Property tyLine . .... SEEPAGE PIT Depth _ Diameter ....'---._...... Number ............................. Rock Filled Yes ❑ No C ' Water Table Depth -•------------------------------------ .........Rock Size --------....._._...._.._. ...... Distance to nearest: Well ----------------- -- ..................Foundation ................ Prop. Line ......................0 L. REPAIR/ADDITION(Prev. Sanitation Permit# ............. •------ .............. Date ------------_......................I Septic Tank (Specify Requirements)........................................ -- �-___.__......--_-_- - . --------------- ------- •- •. ...... Disposal Field {Specify Requirements) ... o. - ..__... ._. k 3 ----------------------- --- --- --- . ------ ------------------ ------•... -------- ..----------......-----...----...._......_....._...••.......... (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 San Joaquin Q County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or lice 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 suchmanner as to become subject to Workman's Compensation laws of California." Signed ---•-- ----------------------- -- ----- ----------- -------------- Owner �- f L BY --- _. --------------•-- ........ Title ... i (If other than own FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y __�Y... __ _. DATE .,1. .:7 ---•-- -.--•--------•---- ... : _. .w. BUILDING PERMIT ISSUED __"- --------------------------------------------- ----.----.•-•-._DATE ...".._._..__._.._.._....---...-----...__.. ADDITIONAL COMMENTS ------------ ------ ------------- - -• ................... --••------=-------•---------••-------- -------- --------- ----------------- ----- ------------------.._-_...._.--------------..-.._.__-_.._-_--------- _----------------. . - Final Inspection bY ' Date �.. � ....... ----------------------- ---- ---. - EH 13 2L 1..-68 Rev. 5i SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M