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FOR OFFICE USE FOR SANITATION PERMIT .................- .................... . .. ... ....... �ZCOAPPUCATION (Complete in Triplicate) Permit No. Y ............ ........... This Permit Expires 1 Year From Date Issued Date Issued .e!6Y 7y. Application is hereby made to the San Joaquln 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/l TION .... ..-...CENSUS TRACT ... . ................. . /.. . .:.. . . . ............. .......�'. . .... ....... . Owner's Nam .......... ... Phone Address ------ .. ....... .............................Ciry ... . ... .. . ...... ..... ...... ... ......... Contractor's Name .._ .. ................ `...........License # Phone .............................. Installation will serve: Residence (Apartment House❑ Commercial❑Trailer Court =] Motel ❑Other . . . _.................................... Number of living units.... Number of bedrooms .3......Garbage Grinder Lot Size ......... ......... Water Sppply: Public System and name .........-----•..............................................:..............................................Private—* rivate [ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loom% Hardpan❑ Adobe ❑ Fill Materia) If yes,type ............................ (Plot plan, showing size of lot, location of systemin,relation to wells, buildings., etc. must be plated on reverse sw.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is ovailable within 200.feet,) PACKAGE TREATMENT [ } SEPTIC TANK } Size.... ......................................... Liquid Depth ... ........: ... .... Capacity .. _.._ _.. . Type ... ...... ... Material.........:............ No. Comportments ......,. ......... Distance to nearest: Well ... .... ..:....................Foundation .,.._ :.,...:. ...... Prop. Line .................. LEACHING LINE [ ) No. of lines . ... . _... - Length-of each line. ... Tatcl- Length I.............. 'D' Box ... Type Filter Material.. .........:......Depth Filter Material .......... .. ............. Distance to nearest: Well ......... ... .......... 'Foundation ........ Property Lire . ...................... SEEPAGE PIT ( j Depth Diameter ................ Number . ....... Rade Filled Yeas ❑ Na Water Table Depth .......... .:...:..` ....................Rock Size ................................ Distance to nearest:Well . ...... ......... ........ .Foundation ............... . Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ........ ........ ._...... .............. Date .................................:) Septic Tank (Specify Requirements) ... .... . .. Disposal Field (Specify Requirements) .... ... *..... .. . - - . :-..... ........ .. ..... ------.................... .. . .i ,.............:........ ...........................---. .... .................... ---...._. (Draw existing-and-required addition onreverseside) I>hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County Ordinances, State taws, and Rules and Regulations of the Son Joaquin local Health District. Home owner or fto* sed agents signature certifies the following; "I certify that in the performance of the work for which this permit is Issued, I shell net employ stir person lin such manner as to become subject to W man's Compensation laws of California." Signed -•......... .... ... .... n .... Owner By ... ................ . �!...-. .._.. Title _. ..._ (if other than owner) FOlt DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . .. ...... : ...... .: .................... ......... DATE .... .. BUILDING PERMIT ISSUED----- ......... .. ....:... ...DATE ..... .... -.. . . ............. ` ADDITIONALCOMMENTS .... . ... ........... ........... . .................. ......... ....... ...... ....................... ......................................... Fina{ Inspection by. .... '.... ... ................. ..... ... .. .Qote .. ..:�'. ..... .. ..... SAN JOAQUIN LOCAL HEALTH:.DISTRICT 13 24 '68 Rev. SM 7172 3 M