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FOR OFFICE USE: -_ APPLICATION FOR SANITATION PERMIT ......... ........................... Permit No. _:... ......... (Complete in Triplicate) -'.......:.---..... . ... ....................... ............ ................... This Permitl»xpires 1 Year From Date Issued Date Issued 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.Ord!nonce No. 549 and existing Rules and Regulations: •: ,. ' -� 4 ...CENSUS TRACT JOB ADDRESS LOCATIO �gA /3. . ' S Owner's Name . .. ............Phone ................................... Address ............. - . City .............. ..... , Contractor's Name tt' ........... -• •• •-• ..�ti..� License # Phone ' ! i T: Installation will serve: Residence r-trA artment House Commercial Trailer Court 01 Motel ❑ Other ......__.................................... 11 y Number of living units:.....`-.... Number of.bedroom' s ....��.-.-.Gorbage Grinder .............Lot Size ..... -X/P.0............. 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 ❑ Fill Material ............ If yes,type ............................. (Plot pian, 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,) PACKAGE TREATMENT [ ] SEPTIC TANK fl .t3� YUf-- _.: Liquid Depth .. .....Y............... Copacity`.oC. v.. .. Type,�. .4p�', r�✓:--Material.-Orin--,,. No. Compartments _ ................ p4 Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE.. [ ] No. of Lines .' __.._____-_. h Length of each line_____________ _____ g J •---•-----'- --..._... Total Len th'---._ ........---•-----. 'D' Box ------------ Type Filter Material .....•.:.............Depth Filter Material :_"...._....................... .:-- 43 Distance to nearest: Well ...............:-.!:...... Foundation ...- --•--. -------- Property Line ._.....,........:...--:.:,.Y,, SEEPAGE PIT [ ] Depth ..................... .. ............:... Diameter ,... Number ............. Rock Filled Yes [] No t❑� 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) ................ •--•--•-------•-------•-------------•-•........---.....---••---•------•••---•-------....--- .._._...-•---•--....---••--••-------------------•--•-------_--------------------- ............. ......�.............................................................. ,.... --------•- •----- ------•----------------- - ----------•-------------._._._..._.........................•---.:........=-----...----•-•-•--•......--- (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 San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner, or licen- sed agents signature certifies the following: .. "i 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 ------ --- Owner (If other tho one FOR DEPARTMENT USE ONLY q9 ............ ----•---•---•-•---. DATE BUILDING PERMIT ISSUED _.._y:. .._::......_DATE ..........:............. ------.....•. ....._..... ADDITIONAL COMMENTS ---------------------------------------------- -- .. ... ...•. . ... . --•-•-...... •--••-.._..- .................... a�•._............- ---- -------- - . ------.. -- ---._. _............. _....... �?..... Final Inspection by. ......... .. .. ... ..._.._....... =._. ...._ ..... Date._ Com`•• e� { SAN JOAQUIN L CAL HEALTH DISTRICT E..H.13 241 '68 Rev. 5M 7/723 ,4