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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .................................. Permit No. ........a...- (Complete in Triplicate) ........................................•--•-----...._ Date Issued r......................................................... This Permit Expires } Year From Date Issued 1 Application is hereby made to the tan 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 ADDRESS/LOCATION ...... Owner's :cI:NSUs TRACT Owner's NameI .......__. 0 ---v�--- - - -- - -- _._.....- - - . . .......-•------...,... ..... ......._...._..--- one -------•--------- ----• Address .. blG� z� . city ---- - ----- ... 10 Contractor's Name ........ ... --- _ License # _ Phone fInstallation will serve: Residence Apartment House 0 Commercial ❑Trailer Court 0 fMotel ❑Other ..._...-----••---••--• ------•--••-... .--- Number of living units:......... Number of bedrooms ....3.......Garbage Grinder ------------ Lot Size -----�_�_._..___. Water Supply: Public System and name ........ ..................... ------ ............ .................Private Character of soil to a depth of 3 feet: Sand 0 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 tc_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-[ ] Size................................................ Liquid Depth ...... ............... Capacity ------------ -_.. Type .................... Material-------------------- No. Compartments ...................... 0 Distance to nearest, Well .. Foundation • .................•----• ....._._... ..--•--•..- •-•---.. Prop. line ---•--••----•-----•--• rn t LEACHING LINE [ ] No. of Lines ........................ Length of each line............................. Total Length ........ 'D' Box .._ ..__..- Type Filter Material ....................Depth Filter Material ---._..._.:-__.._.__....................:_.. Distance to nearest: Well ------------------------ Foundation ------ ................. Property Line ........................ i SEEPAGE PIT [ ) Depth ..__::�.............. Diameter Number ............................ Rock Filled Yes (3No 0.0 0 i • Water Table Depth ..................Rock Size Distance to nearest. Well ----------------------------------------Foundation ..... Prop. Line REPAIR/ADDITION(Prev. Sanitation-Permit# -----------------------•------- _----. Date ..........__........._.....,-----_) Q. Septic Tank (Specify Requirements) -------------------_------•--- - ......__...._...•._•••---......... _...----....�..---........... D o I Fie d )Specify Requirements) .. �. �..� .... --.. ...-•.. .....:......... ............. L _ ... -•--•- ` --- ------ ------ ------------------- --------------------------------------------------------- _. ---.------------- ••.......•--------------------............................................................................................ . raw 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 licew 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 subject to Workman's Compensation laws of California." Signed ..............----------------------- ..... -•.- .... •-• ....... -• --- -- •-----..... Owner By ..................................................-......• ---•-•-• Z.. Title ...................................... (If other than owner) I ' F DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .._• . ..... DATE ..� ..' �. 7. . ........... BUILDING PERMIT ISSUED ......................................... ..... ..DATE ADDITIONALCOMMENTS ............................ ---------------•----------------•-•------•----•------ -•--._....--•• -------.............-................................. ...-----•...........................•. ---- . .... --- ----------- ........------ Final Inspection by: .:• _ Date - r ...... ................ . . . ..............................................•---••---------•-... i SAN JOAQUIN LOCAL HEALTH DISTRICT r (X22 F w'13 24 1_'AA vo.. AAA �� 7172 3 M