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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7y3� Permit No. ............"""""" (Complete in Triplicate) This Permit Expires 1 Year From Data Issued ' Date Isikied ..... ...... .. .: Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereirti destribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT ON ...4P.b.!.. ................................................CENSUS TRACT ..................... ... Owner's Name ...... .. . ................................................ Phone Address , .. ....... .. .......City .......................................... Contractor's Nome .... . .1--e....... . ...... . . ...............License # Phone .&4(a ..YJMA. Installation will serve: Residence OM!�-►4part ent House f0-1 Commercial ❑Trailer Court 0 Motel ❑Other ............................................ Number of living units:....../... Number of bedrooms —3 Grinder ............ Lot Size ..7 A*'.J "................ Water Supply: Public System and name ........ ..............................._..........-_..--------.--.-....................Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe.E!!r'Fill Material .........--- 1f yes,type ............................ (Plot plan, showing size of lot, location of system in relation to wells,:buildings, etc. must be placed on reverse side.) 0 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer,is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK I ] Size......./ ................... ..... Liquid Depth ........................ Capacity ... Type .................... Material---------------....... No. Compartments ...................... Distance to nearest: Well ................... ......Foundation .......... Prop. Line LEACHING LINE [ ] No. of Lines .........1............. Length of a ch line---....,,1'41.,.......... Total Length ., .� ..... 'D' Box ..._!�`- Type Filter Material ......, ..`.'....Depth Filter Material ...Jk610000........................ . Distance to nearest: Well .:;,,10.._....... Foundation ..... Property Line ........................ SEEPAGE PIT [ ) Depth .._.IJ:/.... Diameter Number ck Filled Yes Imo' No Water Table Depth ...........................Rock Size ...___/.. ..-................... Distance to nearest: Well ..... ..........::...........Foundation ...... Prop. Line ...... REPAIR/ADDITION(Prev. Sanitation Permit# ..................... ate .................................. ) Septic Tank (Specify Requirements) .......... Ke Disposal" Field (Specify Requirements) .--•----------------------------------------------•----•---•--•---..............----•--•---------.....---------.........---------•--. ...................... ....•-------•........._._...•-----------------•-----......•.......---•-...._........-----------------....----•-----------.................•--------_......I.................------- --------------------------------------•---.....---------•-----.......-----------_......---•-----•----......................................_................................. (Draw existing and required addition on reverse side) I hereby)thh tify that I have prepared this application and that the work will be done in accordance with San Joaquin County Onances, State Laws, and Rules and.Regulations of the.San Joaquin Local Health District. Home owner or licen- sed agengnature certifies the following: "I certifyt in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to becsubject to Workman's Compensation laws of California." Signed . .... 1 .......................... Owner BY .! . . . -.�...`.....-----•-•......................... Title ..._. . .........................---•............. (If other thap,,6wner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B ...................................................... ..... DATE ................. BUILDING PERMIT ISSUED .. ................................................... ...---............DATE .................................... ADDITIONALCOM4AENTS .......................... ......................................_.........................._...._........................................................... ......--•--------•-•---------------•-.................---...... ... . ------------------.......-----.....---------------.....................-•-....................----------------.................... .............................................................. .... ._.._. ...........................,.................................................... ............................. ... ..... ... .. .�,�. !`.'............_........... ._........ ._............ Fina Ins ection b p y^ _ . �� ............................Date . � c./.. . y�.............. N JOAQUIN LOCAL HEALTH DISTRICT l 13 24 E. H. 1-'68 Rev. 5M 7/72 3 M