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FOR OFFICE USE. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r � p Permit No./q- -------- _----- (Complete in Triplicate) ----------- .................................. ............ Date Issued-. --.- --'--=> ................... This Permit Expires 1 Year From Date Issued Application is hereby made to.the San Joaquin Local Health Disti:ict.for a permit•to c nsffuct;ond install the work herein described. This application is made in compliance.with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION -- ---- - ------- CENSUS TRACT..-.--. 9 °°�` f� Owner's Nome.... ... �• :. Phone.. .... Cit ..... --...._zip- Address----...._1-f.�/ ....+�- � . el - - Y----•--..-•--- �-- ----...._... •��,. fa IN Phone. f p-�� .. --"-• I Contractor's Name..... C- - License #. ',.... f Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ - Motel ❑ Other.... - ......... ----- - - -- i� Number of livingunits:.__... Number of bedrooms....-'Y..,- -Garbage Grinder._..-..-----Lot Size-.--- ��` �- 4 / Water Supply: Public System and name:.._... -- -•-"-- --- ....... .: ------------ ---.--Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clai,,LOCImA " 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 if public sewer is available within 20a feet,) ~ Liquid Depth............ PACKAGE TREATMENT SEPTIC TANK Size MNo. Com artments....�:.------------ --.-.-..--.- Capac•ty. /4.D.Q "-"---T e" aterial. ..".-.-..- 1 I Distance to nearest: Well._..------1.0.-D- ...--"-4 Foundation..._fG. . . Prop. Line-.`C----------------- LEACHING LINE [ ] No. of Lines -_�- ----------- ------ Length of each iine._� y..-.----•- - ...Total Length -- D' Box.:... .....Type Filter Ma#erial... ...1_.. -�Depth,.Eilter Material.......!_......... ".- . - - '� "�•.. .... _ _ Distant to ne rest: Well_. :-:=111:0... Foundation...-.-`"�;----�_-- Property Line_.,- _ _ - - yloye I " -"""_.""-.- Rock Filled Yes; No ❑ Deptli-klax/e`�sDiameter_-----_-..- .--.Number._..."_�� •---•......_ Water Table Depth----------------------------- -Rock Size--.. _ Distance to nearest: Well.------1,0Q------- -------- Foundation---- �;?...... ......Prop. Line..-__..----_- ---- REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------I.. ......... Date-_--------------------------- Septic ------•----------.--- ----5eptic Tank (Specify Requirements).... ---- - ----------- ----•-•---- ....----- ----------.-. --------- Disposal Field (Specify Requirements)....................... ....".-- --- -- (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 licensed agents signature certifies the following: r "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 subject to Workman's Compensation taws of California." Signed---------"------ --------- --- --------- .. .... _----------- ........ _.Owner Title -�&o -- ..................-"- (If other than owner) FOR DEPARTMENT USE ONLY DATE -- .�Z .Z ........ ........... .. APPLICATION ACCEPTED BY---------- - -- - . DIVISION OF LAND NUMBER...------ ----- ... "-"---- DAT .---.. --------•--- ---• -- -- -------------- . ADDITIONAL COMMENTS.. ........" ----- ----- ----------- ------ --------------I. ---_•. ... ................ ._. -"...................... -.-_.. .. - .... . Date.-._ � - Final Inspection by:......_..."----.-...: " A Fas iib» Rev. > >e ann EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT