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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ........ . ............................................. Permit Na. _�7:......... (Complete in Triplicate) . .......................•......• This Permit Expires I Year From Date Issued 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOCATION - -..... ..:�....... .............CENSUS TRACT ` p........ .:.......... 12 Owner's Name . ..Phone S . ... ...Address ...................................... ........ •-•-•- ---.•-•-•--•....... City Contractor's Name ................ : �.��3*3.. Phone -�6&� T-Zqa- _ Installation will serve: Residence 8 Apartment House❑ Commercial '-❑Trailer Court.0 { Motel ❑Other ...... .............. ................ ff Number of living units:...... _.., Number of bedrooms ....Garbage Grinder ._.'.___ '_.;Lot Size ..... : Water e.._ -Supply: Public System and nam :--------- .... ...... M _-•. �.. # _=—•— —_: Private [ZJ( Character of soil to a depth of 3 feet: Sand .Silt❑ Clay ❑ Pent Sandy Loam {] Clay Loam ❑; Hardpan ❑ Adobe ❑ Oil[ Material ............ If yes,type ....... ..............t..... (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 if public sewer is available within 200.feet,) .. PACKAGE TREATMENT [ ] SEPTIC TANK i ] Size......................................... Liquid-Depth ...__........ ... ---- Capacity --------- Type Material:.:....=._.. -.No.--Compartments...... ...:.._..._1..-- 1 �. "Distance to nearest: Well ....................................Foundation .........._.......... Prop: Line ............--........ LEACHING LINE [ ] No. of Lines ------------------------ length of each line........................."I Total' Length. ............................. V 'D' Box --------.--. Type Filter Material ........... :......Depth Filter Material ................-.......................:_.. c Distance to nearest: Well ...... ................. Property. Foundation.-....................... Propy Line ...........-:.._.. .::.. � _ r SEEPAGE PIT [ ) Depth Diameter _- Number ---- ;` ................. Rock Filled Yes p s'-No ❑ m • Water Table Depth .................Rock Size a, Distance to nearest.• Well _. ....Foundation .. Prop. Line N' REPAIR/ADDITION(Prev. Sanitation Permit# ........................................ D -------------- Date ........------------•-•--•-••-•- i Septic Tank (Specify Requirements) .................................--.................. l--i-.. ----..........----•-•..........----......._....__...---•--........ Disposal Field (Specify Requirements) _-_- ... ............ .... ......................... -•-•---•-•- ----------- ......... ........... - --- - ----- .. - _ - __.. ________________ .............................................. ---------------------- _.................................................-.................................. ._.•-.• (Draw existing and required addition on reverse side) 1 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, 1 shall not employ any person in such manner as to become subject to Wo kman's Compensation laws of California." Signed -------- - . ........---•----• •. Owner . .. .......... ................... ...... Title .... .. .. .................................................__ (if other than owner) FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... f • DATE ..... .. � .p. .��. BUILDING PERMIT ISSUED .............................................. ---- .:.......:.............--------------------------------DATE ........................................... ADDITIONALCOMMENTS -----------------------------------•----•--..........----- •-•----------- ...............................................................1.................... .............----•--•------------------••-----•---------•-------•- ----•- -•---......... --._..... ------•- _�} Fina( inspection by: :. a� -•---•Date .....�.�/ .�.. ............ SAN JOAQUIN LOCAL HEALTH DISTRICT �3 7172 3 M