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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ?S-�2 ` (Complete in Triplicate) Permit No. ................... . .......................................................... ` S ........................... V 'this Permit Expires I 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 mode in compliance with County Ordinance � No'. 5549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..,../`"0`. '-;;:3 ,---..-. ,.s� �.................CENSUS TRACT .... .. . . .. . .......................... Owner's Name < .........Phone Address l C�.-- •! c _._ . "..............• City ..- - = .................... . Contractor's Name ....---- ..............license# Phone CP Installation will serve: ResidencebdApartment House Commercial❑Trailer Court ❑ Motel ❑Other............................................ Number of living units:_.-..r.... Number of bedrooms ..... .--Garbage Grinder ............ lot Size ..., r 4 .....li. ......... Water Supply: Public System and name ............<R . ..---.-.. _=les -................................................Private❑ Character of soil to a depth of 3 feat: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom❑ Clay Loam ❑ Hardpan❑ Adobe 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 side.) NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,( PACKAGE TREATMENT j ] SEPTIC TANK Size......I-'x .i .A .....�.............. Liquid Depth ...-n2............ Capacity/7-4'.'f?.------ Type l%t"e-CW. lMaterial...deW �qVo. Compartments ....."?...... Distance to nearest: Well ......,eta _ .........Foundation ....< e!.r Prop. line ....... 2 LEACHING LINE No. of Lines .........1............ Length of each line....../ Q............ Total length ...........�►� V Box ...../-- Type Filter Material .-r-.e .Depth Filter Material ...............?.�................... tA Distance to nearest: Well _/llfv.a✓L ... Foundation ------- ..F,J.'..t...... 1r6perty Line .......S. SEEPAGE PIT �Q Depth -----" Diameter ..,31..... Number ........../................ Rock Filled YesA No IV Water Table Depth ........../4.a!........................Rock Size .........21-11-............. y1• Distance to nearest: Well ..... ...-.......-........•....Foundation .....1-0. !..... Prop. 1. REPAIR/ADDITION(Prov. Sanitation Permit# ------.---- --------------------..---...._. Date ..................................) �p Septic Tank (Specify Requirements) ..................... Disposal Field (Specify Requirements) ........................................-............................... ..................................................................................................................................................................................................... •---------------------------------------------------------- ------ ............ ...............--------------............................................................................................ (Draw existing and required addition on reverse side) ! 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 HeaHh,District. Meme owner or licow 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' Compensation laws of California." Signed ------ - :. - Owner BY �... -------- - ----------- ............ Title ..--- - - (If other than owner) FQR DEPARTMENTS SE ONLY APPLICATION ACCEPTED BY - = ------ ....... DATE .. -...-..:..��.-_: BUILDINGPERMIT ISSUED -..----•--- --------- ....... ....... ............ ..........----------------------------..........DATE --------------.............. .-.......... ADDITIONALCOMMENTS .----..... .................... ........................... - ----------------------------------------------------- ----------------- ..............................--- --- - .......... .................................... 44SAN ------ ------- - ------•--- ....... ......-..-. .....--- ----._....._........ ............-._.._.. ------------------------ .-_.. ._.. . ;�, j Final Inspection by: . Date ............... EH 13 2!' 1`' OAQUIN LOCAL HEALTH DISTRICT 8/7h 3M