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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ... ........ . .... .....•--- ------ ---- (Complete in Triplicate) Permit No. ..................... t Date Issued t This Permit Expires t Year from Date Issued " .....J....................•-- 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 .. .. .,��.. .�,. �. ...... ....CENSUS TRACT .......................... Owner's Name "......, i� ...................................../. .:................Phone ....._... .. t.......... Address ./! .. ..../ /`.... Contractor's Name .-. £ T —1 ,...........License # ��=9S-5Z173. Phone Installation will serve: Residence Apartment House 0 Commercial[]Trailer Court C] Motel❑Other............................................ e Number of living units:... ........ Number of bedr s ... .......Garbage Grinder .AfI6... Lot Size ...�f.]...�.` .r.......... Water Supply: Public System and name ......... -.( ..--....w......K..... ............................................................Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑1 Clay Q Peat❑ Sandy Loam Q Clay Loam [3 Hardpan(] Adobe Fill Materlal ............ 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 seepage pit permitted If public sewer is available within 200 feet,j PACKAGE TREATMENT ( ] SEPTIC TANK{ j size...... .................... Liquid Depth ........ Capacity --1440..0..... TypePZZ . Material..ee C.7.... No. Compartments ...Z .......... � � E Distance to nearest: Well .._....-. d!>— X.., .......Foundation ....l.,ga.......... Prop. Line ... ........ LEACHING LINE ( j No. of Lines ............... Length of e . .. .. Total Length S ............... D Box Com'.. Type Filter Ma erlal Depth Filter Material ..../..�.11.............................. Distance to nearest: We .. . ._ Foundation ../10............... Property Line -.?.................... SEEPAGE PIT ( j Depth --.?, .--_. Diameter ,3.(....... Number ......../.......... ...... Rock Filled Yes o Water Table Depth ..... ...............................Rock Size /..;k-- Distance to nearest: Well ..... .. .—.............Foundation .�'C .-..,.... Prop. Line ..s,$.............. REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ..................................) SepticTank (Specify Requirements) .............................................................................................................................................. Disposal Field (Specify Requirements) .•-•--•....... •-••--••.............................•---------............................•-•........ --------•------------------ -------------------- ---------------- ..........----....................................................................................................................... . •---------- -------------- ------------------------------------ ...............-............................_............................................................................................ (Draw existing and required addition on reverse side) I hereby certify that 1 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 HealHs District. Hoare owner or licen- sed agents signature certifies the following: "I certifythat a performance of the work for which this permit k issued, I shall not employ any person in such manner as to becom s :-e: t wo man's Co ensation laws of California." Signed _..... .... .. - _ ..--• --- Owner By ...... -- ----- 7it1e __ __. ............ �. ...................... (If other o ner) FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY _-- . ._ - _.............. DATE BUILDING PERMIT ISSUED ... ': -.. ..............DATE . .............................. ••••-...... ADDITIONAL COMMENTS - ........ ................... ------------ - -------- ........ --.................................. .......................................... ......................... ..—......------. ...................... ---------------......... ---------- ----------- J- ................ ........ ---- . --•---. ---------....__.._----.... -•--._... ............. -•--- ----- ------.. . ....... . . ... Final Inspection by: .... ..... -----• Date --- .......:p�. - rr........... EH 13 2h 1--6£3 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M