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FOR OFFICE USE: ............................... APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicates 7 ............................... ........................ This Permit Expires i Year From Dote Issued Data Issued ....l.Q.:.�? Application is hereby made to the San Joaquin local Health District for apermit to construct and install the work herein ! described. This.i application is made in compliance with County Ord' ante No 549 and existing Rules and Regulations: J013 ADDRESS%L CATION ......... :_..'..............CENSUS TRA _- Owner's Nome ...........- .._ . .............:.. _ ._Ph Phone Address ..__ 1j..7City . 1- 41 , . License # .� _7. Phone Contractor's Name ... ,�, �- Installation will'{serve: Residence Apart nt-House Q Commercial (Trailer Court, Q ' Motel ❑ Other ............... Number of living units:--/-.,.... Number at.bedrooms .;•.....Garbage Grinder ............ Lot Size .. Water Supply: P,ubl is System and name ..................... .. ' -------•------••--- ---------------••------=----......••-•--. ---- -•--••-•-------.Private [] Character of soil to a depth of 3 feet: Sand�] ' %..i Silt❑ Clay ❑ - Peat[] Sandy Loam Clay Loam Q.. a FHardpan ❑ Adobe ❑ Fill Material _.._._._:_ ..if yes, type ----_._.......___-.--____ _. (Plotfan, showin y P I g,.size of lot, location of system in relation to wens, 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 l - Size.��,� �.__—��--..............---- liquid Depth _..�.�-- Capacity/�`� ....-: Type _ Material No. Compartments .. j Distance to nearest., Weil g _. - :Foundation � _ ._. Pro Line .4..................... LEACHING LINE! E ) No. of Lines ... .................... Length of each line...................... Total Length -------•-••-•- - ....--•--•-- 'D' Box Type Filter Material .....Depth 'Filter Material z Distance to nearest: Well ....----•-- ......... Foundation ------------ -. Property Line ........................ SEEPAGE PIT ._...._.. Diameter [,Ij Depth . Number ..................... Rock Filled Yes ❑ No Water Table Depth ...............................•.......Rack Size ;i i Distance to nearest: Well ..................................:.....Foundation .................... Prop. Line ...................... REPAIR/ADD1T10N(Prev. Sanitation'Permit# .....................17......... Date _... .....-:---••-.----------.----) Septic Tank ISpecify Requirements . 106_�-... " --_ ,� _.... w Disposal Field {Specify Requirements) ...-__..-•••............................ I --•--•------•....--•-----•-------•--••---••---•---• ---- ................. ----'' .......... ... •. •---------• -----• -------------- ----------------------------------- ---------------- Draw existing g 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 agentssignature 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 Co sation laws of California." Signed ._ ...... :L -----• --- =� -•---- -------- ---------•-•-----------......... . Own r e BY (I 'other than ner) ................:................•...... Title ....... ........................................... 'I ' FO IEPARTMENT USE ONLY APPLICATION ACCEPTED BY . ---- ---- .................. ........................................ DATE ../-_.- . BUILDING PERMIT ISSUED ...................... DATE .............................. ADDITIONAL COMMENTS .......................... _........._._. .....................................----------------------I� .........................�.. --------...... __......----............... _----..................... .. - ----------....... __. _ ........__...._.__.......__.._._.___.........-.._-._.. !� _ _.._..............._.... ...............:.............................. Final inspection by: ......r ! ... .Date .._.._.. ----•----•-- SAN JOAQUIN LOCAL, HEALTH DISTRICT i F u 13 24