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F6R OFFICE USE: APPLICATION FOR SANITATION PERMIT �.... ........................ Permit No. ...:5.�� .......,.................... .f�'................. (Complete In Triplicate) ......... This Permit Expires 1 Year From Date Issued Date Issued .7..... .�y Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made In compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION �.�.7....�..�= ... �f.......................................CENSUS TRACE' ....................... . Owner's Name . r.. .:.. ................................... Phone . . .... . ...... .............. Address ....... . G�X�...Z.. . t .... ....-4-11a ..................... Ciry u.................... .... Contractor's Name ......... ...� .. ��►,FG., �.:::..........License Phone .............................. Installation will serves Residence M-A-portment House❑ Commercial ❑Trailer Court 0 Motel ❑Other ............................................ Number of living units,....,..... Number of bedrooms ........Garbage Grinder ............ Lot Size .....�.....:t-..-...... ... ... : Water Supply= Public System and name ... . .................................... ............... ... .. ....Private ... ..... .... ............ .... ... ........ Character of soil to a depth of 3 feet: Sand D Silt❑ Clay ❑ Peat❑ Sandy loam Clay loam ❑ Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ............................ (Piot plan, showing size of lot, location of. system in relation to wells, buildings, etc. must be placed on. worse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 0 PACKAGE TREATMENT ( ] SEPTIC TANK ] Size................................................ Liquid Depth .......................... r/ Capacity .................... Type .................... Material...................... No. Compartments .................. .J Distance to nearest: Well ....................................Foundation ...................... Prop. line ......................IE 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 ................:....... 2 SEEPAGE PIT ( j Depth Diameter ................ Number Rock Filled Yes ❑ No-C7w .�._ 0 WaterTable Depth ................................................Rock Size ................................ Distance to nearest, Well ..................................... Foundation .................... Prop. Line ....................». REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................) Septic Tank (Specify Requirements) ..........................................l....-.+:.... .... ................... Disposal Field (Specify Requirements) .. .. .. ................... . ?. , ....... . .,,� ....... '..... . �.- ... v/ .. ............................ ........................... ...................... ....... .......................................................... (Draw existing and required addition on reverse stdej 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 Ilcen• sed agents signature certifies the followings "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 orkman's Compensationlaws of California." Signed .................... .... ......... t�! >•`f" ................................ .L.......................... Owner (If By ..... ........... .f other than own... n owner)�� ... •.>• �.�..................... Title �...... .. .. ... .. . .......................... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ............. ............................................................................, DATE ..... ......... BUILDINGPERMIT ISSUED ........................................:..................................................I..............DATE ........... ............................... ADDITIONALCOMMENTS .................................................................._........................................................................................... Final ins action b z ..................... ......................................................................................: . .b�. '. .. ............ . ... .... .... ....... ..: PY ..... ........................................................................................Date .........,� ................ SAN JOAQUIN LOCAL HEALTH DISTRICT CD E. H.13 241•'68 Rev 7/72 3 M