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FOR OFFICE USE: ........_.. APPLICATION FOR SANITATION PERMIT `fis (Complete in Triplicate) Permit No ......... �- �..... =�-- r--�... ... �3 ............ ............................................ This Permit Expires t Year From Datelssued Date Issued .14..!�/::7f 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 . .� : .. V ... ._.. . ... ......................CENSUS TRACT . �� ......:......... liOwner's Name -. - . ................. ... . .......................................................Phone ..._......... .•......�ii Address . Contractor's Name --- _...._ , -- License # .(. �� ... Phone . / . e . . . Installation will serve: Residence❑Apartment House Commercial❑Trailer Court Motel ❑Other............................................ Number of living units:.-....___.._ Number of bedrooms ............Garbage Grinder ............ Lot Size .............. . .............................. Water Supply: Public System and name ........................................................ ........Private❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy Loam 0 Clay Loam Hardpan❑ Adobe p 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 slde.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 240 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size......................:......................... Liquid De Capacity Material......_...._•__....... No. Compartments 0 -------------------- Type ---------•-------•-- pa .....................-4 Distance to nearest: Well ....................................Foundation ...................... Prop. Line .....................W LEACHING LINE [ ] No. of Lines ---I-_-_---..._.-_ Length of each line.......L4,0............. Total Length17 'D' Box ..--_-___ Type Filter Material ....................Depth Filter Material . . ....... ............................... Distance to nearest: Well -.--..--_------------- Foundation ............. Property Line ....................... SEEPAGE PIT ( ] Depth�k / imeter ................ Number ........ ................... Rock Filled Yes No Water Table'•Dep#h ------------------------------------------------Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. Line...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ..................................) SepticTank (Specify Requirements) ........... ..•---•----••--------•••••---•••-•------•-•-••-..........---------....__..........---•-......................._.................. Disposal Field (Specify Requirements) ............................................•_-•-------•..._._..._......._._......_._... - ----------------------------------------------- --................................................................_...................................... . -- --------------------- - ----------------- -- ------------............................. --...........-•-••-•--...---•••............................... (Draw existing and required addition on reverse side) 1 hereby certify that i have prepared this application and that the work will be done In accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Home owner or licew sed agents signature certifies the following: "1 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 --.-- -- a Owner BY - 1._ ... ..................... Title (If other than owner) 1FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY c_ DATE �7- BUILDING PERMIT ISSUED ..__.. .. ............ .......DATE .. --------•---••----.... ADDITIONAL COMMENTS ------- ............. ..............---................. __..... Final Inspection by: _.: ,.� -- ------------------ ------- - -........................................ .. .._ --- --►--- - .............. . . Date . ;? +�... Ell 13 2b 1-6 R • 5� SAN JOAQUIN LOCAL HEALTH DISTRICT