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FOR OFFICE USE: �/ rd APPLICATION FOR SANITATION PERMIT c ...........-5V11._............. " 4.5 (COMA!- Permit No. ete in Triplicate) ............................................. This Permit Expires t Year From Date Issued Date Issued Imo.: :..�.y 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 .......L/--. ..................... ......._ ........ Phone_I L7 -�. .1.......,- Address .... .... ..`_�.9.�P1---• ............................... City ....,..... Contractor's Name ...... .....-- G .• O sT ......................License # "3y ._.... Phone6�>- ..... Installation will serve: Residence*partment House❑ Commercial❑Trailer Court 0 (� Motel ❑Other ............................................ N, Number of living units ..... Number of bedrooms .... ...Garbage Grinder ............ Lot Size ....,/ Water Supply: Public System and naive .............................. Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay loam ❑ Hardpan ❑ Adobe W Fill Material ............ If yes,type ...............:............ (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted ifpuubic sewer is oyailobie within 200 feet,) �s PACKAGE TREATMENT SEPTIC TANK f ize.... /......X. !P ......... .. .. liquid Depth ._..�!}.............. Copacity,t!�w. ...r��. Type Material... ........... No. Compartments .. ........... Distance to nearest: Well ..•........ Q...............Foundation ...J.D............. Prop. Line ... ` LEACHING LINE '6Q No. of lines ........./............ length of each line........ ........... Total length .....a5 ............... 'D' Boz F� Type Filter Material p ` .................................. it ...._ ...... ......De Depth Filter Material! ....- -- Distance to nearest: Well d.rf....... Foundation .......4-0..'±..... Property Line SEEPAGE PIT Depth .... .. ... Diameter .�.;3.,..... Number ...........1.............. Rock Filled Yes No C3 Watbr Table Depth .........Rock Size Distance td nearest: Well ......lS . .. '...............Foundation ....1..Q...: Prop. Line .... f'........ REPAIR/ADDITION(Prev. Sanitatipp Perm►It# ...................... ........... Date ) Septic Tank (Specify lfegUirernents� •......................... ..-•................_......--•........... _ ........ .............-.. ..........._..-•-•-•......... Disposal Field (Specify Requi 6ments) •.........................•-•-•--•-•--- ................. --••-•--••-•-•--•--•--...................---•-•--•••...------....-•-• .....-•---•......••-•••........._........................... (Dra existing and required addition on reverse side) 1 hereby certify that, I`shave 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,Health District.Home owner or licen- sed agents signa`t'ure tertifies the following: "I certify that in the performance of the work for which this permit is issued, shall not employ any person in such manner as to become subject to Workman's CorMwAation laws of California." Signed ............................. ••-•......... .... ........ .. ........................ Owner By ........ ..... -•--•_.. .......................... Title ...... ................................................. ,. (If other n owner ti FO tt DEPARTMENT USE ONLY -117 APPLICATION ACCEPTED BY . _... .............................................. DATE ................. BUILDING PERMIT ISSUED ......................................................................................................... ...DATE ........................................... ADDITIONAL COMMENTS ........................................ ...............................................:........................... ................................................. •r_.._...............-5 .;.......... .............................--.................................. Final Inspection by: .. d .�J'IS...::...;. .,1. ... Date .4 . J: 7•c/ 1 ,Ud L°la IioO( SAN JOA4JIN-10CAL HEALTH DISTRICT QD X24 U41' E. H. Rev. 5M