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I, FOR OFFICE U5E: APPLICATION FOR SANITATION PERMIT J (Complete in Triplicate) Permit No: .. ...................................... ...... This Permit Expires I Year From Date Issued Date Issued -7`--.3 Q•,7� Application is hereby made to the San Joaquin Local Health District for a permit to construct and'Anstall the work herein described, This application is,made in Yorr piiance'with-County Ordinance No, 544 and existing Rules and Regulations, JOB ADDRESS/LOCATION ------- [.-.._.. n. _?k .......................... .........CENSUS TRACY ........... Owner's Name . . .�. 't-� on Address .._.._ �................. City ' ' -- Contractor's Name . � t Phone ----..Licenser# �.7 j S , - �c `1. .._��__........ Installation will serve: Residence TIrpartment blouse❑ Commercial 0Trailer Court Motel ❑ Other ..................... / r Number of living units:........... Number of bedrooms ....Garbage Grinder '. Lot Size � ��_.f :.1 ,••._„•,• Water Supply: Public System and name .. � .,_ _-- } r f ( ... _------..... - ................. .....::'Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ -Peart❑ Sandy Loom ❑ Clay Loam.,❑ Hardpan ❑ Adobe51 Material -----------_ If yes, type --------------------- ------- (Plot -- -(Plot pian, showing size of lot, location of system in relation to wells; buildings, etc, must be placed on 'reverse (side.) NEW INSTALLATION: {No se tic-iank"or i6e '�a e- - P p g pit"permittee)if- ublic sewer is ova ilab ezwithin 200 feet,} PACKAGE TREATMENT [ ] S,EPTIC TANKf Size._....._... .___.._._; Liquid Depth...,....... ......... 1 Capacity ............. Type .................... Material---------- No' Compartments ---...•__ ....... ! =- Distange to nearest: Well --------•-----------------•------...Foundation ............ Prop. Line ..................... LEACHING LINE' [ ) No, of Lines ..._ ----------- ----- Length of each )ine---------------------------- Total Length 'D' Box Type Filter Material .-____-Depth Filter Material Distance to nearest: Well ------------------ ---- Foundation ................... Property Line.................. SEEPAGE P17 ( 1 Depth .................. Diameter -- Number . Rock Filled 'Yes ❑ No o- Water Table..Depth Rock Size _____....--- F Distance to nearest: Well Foundation •�°�� _ __ __ _____ -----•---•---••------,.... � ----------------•--. Prop. Line � REPAIR ADDITION Prev. Sanitation Permit# DatQ ' Septic Tank (Specify Requirements) _______ ----------------------------------------------------- Disposal Field (Specify Requirements) f, -F ---.._..-•............................... I (Draw existing and required addition,on reverse side)/ _f, hdr6by 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'Son Joaquin Local"Health Distrlcta Home owner or i€cen- sed agents signature certifies the following: { . f , "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 ........:.... t . i Ow W . ] 1 By _._....... Nle ---- .._._. ........................ oth r than owner} �• �. `— FOR DEPARTMENT USE-ONLY r APPLICATION ACCEPTED BY _.. _. t .. ...� . .. •... :•- •----- BUILDING PERMIT ISSUED ................................ DATE ----------._ __.---.._ . .Q- ,--.y. ADDITIONAL COMMENTS 3 - :e ...- :.::_DATE = -•-- . • - ...........................................•-------......._...................•--_.-•----•----•-•....•_-- ----..----• ...... -- •,� _ _..._..................�- ..-----......_....---......---•----•-'----...•f •--'---- ...........•........................................... ... �• ., --.. ------ Final Inspection by - ---- t --- -----_- --•__:_--Date / .7 .. _ ________________•------------....Dae SAN JOAQUIN LO L HEALTH DISTRICT E. H.13 24 1268 Rev. 5M , ,-.n -3 ,. !