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APPLICATION FOR SANITATION PERMIT ----- .-- - — (Complete In Tr( Perm it No. . �� --+ -- ��-•-- ............. P Triplicate) ... ..... This Permit Expires ? Year from Date Issued Date Issued .. '.'. :,--7 7 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/LOCATIONCENSUS TRACT ... . Owner's Name }z. - , ....... ... .................. Address .� � � � ...... ..... Phone . .... ..... ....... �12 " s,�r'-c� — ... .. .c City - c .. .......... Contractor's Name ... �� .� �„� ---.•r :L.:-------,License # .� c — Phone ....... ...... . Installation will serve: Residence Apartment Housefl Commercial ❑Trailer Court C] Motel ❑Other. ............... Number of living units:.. J.,... Number of bedrooms _-3...Garbage Grinder Water Supply. '�'�'�''�••••• Public System aril name ............................................... ..Private _7� Character of soil to a depth of 3 feet: Sand El Silt❑ Clay ❑ Peat(3Sandy loam d Clay Loam 0— 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 see ge pit permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK I Size. Li � % 1- ...... aAA Liquid Depth _... ' Capacity .Z 'c --- Typ2sry-fMaterial--------• Y T -----.... Compartments ..�,............. Distance to nearest: Wellt4l--------------_-----Foundation ......1..4'.. .. Prop. LEACHING LINE •••••----•- (d No. of Lines ...- Length of each liner--- 4-(G_P ---- Total length ....�.. 'D' Box .J. ..... Type Filter Material .......S--.Z-..Depth Filter Material ........ .41 /r . ......----.------------------ Distance to nearest: Well ...... .t t C:..'. ..- Foundation 1�.. Property Line .... SEEPAGE PIT [� Depth 7 :S`.-� DiameterNumber � _ _ . � ...._ ....... Rock Filled Yes [ No I;] N _ ---_•• Water Table Depth ...--.- --- `j �-'...............Rock Size ....(_./4;2_...X.._�.... . Distance to nearest: Well -------I. r..._ ...........- _.._...._Foundation .....(S-_. Prop. Line ....... REPAIR/ADDITION(Prev. Sanitation Permit# ------------------ . ....- ----•--------- Date ------------------•--- 1 Septic Tank (Specify Requirements) Disposal Field (Specify Requirements# -------------. . .. - - - -------- -- - - (Draw 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 Jeaquirt County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home own sed agents signature certifies the following: er or licen- "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in s as to become subject to Workman' Compensation laws f Califarn( uch manner a." Signed -- --------------- Owner __ title .ti (lf other than owner) . . _. .- . FOILW 41 R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY BUILDING PERMIT ISSUED ---- DATE '�� .7ADDITION _ .DATE ------- AL COMMENTS ... .... ---- -- ----------- --------- - - ---•-------- ------ ------- - ----- - .- ----- ... . - inal Inspection b .....- -- .----- EH J.3 241-6� Rev. �t .. Date . S!. /-� AN JOAQUIN LOCAL HEALTH DISTRICT .. ...... 8/74 3M