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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...................................... Permit No. .7�`..:..��. . (Complete in Triplicate) ...................... ------ ------------ ThisPermitExpires 1 Year From Date Issued Date Issued ................... Application is hereby made to the San Joaquin Coca[ Health District for a permit to construct and install the work herein described. This application is made in corfiplianee with County Ordinance No. 549 and existing Rules and Regulations: 106 ADDRESS/LOC TION ' LZ o .. CENSUS TRACT .................... . ----. _ . Owner's Name ..... .......... ---- ----•------•-•-••--- ............................ Phone .......... Address r .t .5 , . ... city . -..---- Contractor's Nome .. . .. .._. .._.. -� ... ... ............License # _/9'r . Phone ..-------------._..----------- installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 Motel ❑ Other ......... ................. ---------------- Number of living units:......-.._ Number of bedrooms .__.3___-Garbage Grinder Lot Size ............................................ Water Supply: Public System and name ............................................... .---------------- .........................:--------------------Private L!1 Character of soil to a depth of 3 feet:, Sand❑ Silt❑ Clay Peat[-ISandyLoam ❑ Clay Loam 0 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 seep ge .pit permitted if public sewer is available within 200 feetJ...- PACKAGE TREATMENT SEPTIC TANK _ ........... Liquid..._.._ Liquid Depth --- --------•--------... Capacity .'�®. ..--_ Type CO .�+., Material..__.. - No. Compartments -.-- . -� rDistance to nearest: Well� ---------------------Foundation .... fV -.. Prop. Line _.,._.... LEACHING LINE (+� No. of Lines o'Z•_.__ .... Length of each line ... . .ref¢.�..._... Total—Length ......... ..........S 'D' Box __..l Type Filter Material ------Al�.____Depth Filter Material _.._.:/_+y................................ Distance to nearest: Well _.. � �._.. � .��f.i--------- Foundation .� ..--...._ Property Line �.---•-.............. - t SEEPAGE P [61/ Depth Dkmwh-,p Number . _... .............. Rock Filled Yes No [}� t Water Table Depth _..----" _..._a-___.. .-----------'------._Rock Size :_�/.�_..-•a'- -- Distance to nearest: Well .__.._.....,P____________________:_Fouridation I �..Q_ _.......-_- Prop. Line _.,� REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------- -------------- Date ..--------- :-----L_____--_-.I Septic Tank (Specify Requirements) ------------_----------- G Disposal Field (Specify Requirements) ------------------ ------- .._.........-•...................-------------.._................. ................................................. .................... ........ -------.------.-------------------------------------- r ......................... ...............................__..........................-------.�------------- ................. ...................... ..............--------................. (Dro'w existing and required addition on reverse side) 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 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 .... . .............. ....... t-. - - Owner s� . If other than owner) Title - ......... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED _1----- -------------................. ......... ........ DATE _�_.� ��.��..............:_:. BUILDING PERMIT ISSUED .... ............ _.........DATE . ............... ..•--------._...._..----- ADDITIONAL COMMENTS ..................... ... _...._.... .................... ....... ----•----- -----------------------------------------------• ..........•------------------...........•----- ------------------------------------ - ------- Final Inspection by: --........ .T.__. - Date ...... . SAN JOAQUIN LOCAL HEALTH DISTRICT . GO ISTRICT . ti.3