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FOR OFFICE USE: FOR OFFICE USE.: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit ,r. U. This Permit Expires 1 Year From Date Issued Date lssued7:. :.=7. 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.............. ... -...r- �-------------- -- .. CENSUS TRACT....................... -- Owner's Name........-- . ..---- .............. ... ... .. Phone.... ...-. ....------- --....._ Address .......City...... C!-f('�_ -...ziP = ..-... _:.. Contractor's Name_..... Y.U.__.--- ... �' � t -- ------------------License #�. - ( . .Phone { Installation will serve: Residence ❑ Apartment Hou-se ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other......... :-------- ----------- Number ---------Number of living units---------------Number of bedrooms-. _Garbage Grinder- 4.1.-Lot Size.-. _........ r�,- 4 Water Supply: Public System and name--..... _.... _-.--- -----..Private ❑ ---------------•------------- Character of soil to a depth feet: Sand � Silk MpY ❑ t ❑ Sandy - ClaY Loom d an ❑ be Fill ateral._ __ _.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 availabie within 200 feet,) 4] PACKAGE TREATMENT [ } SEPTIC TANK [ ] Size-------------- --------------------------------------------Liquid Depth.---:-..--,- .............. .. - CCapacity_ ---- ------------TYpe...---- ....-------....Material..................... ----No. Compartments-------- Distance to nearest: Well-------------------- -.----.---------Foundation--.---- Prop. Line-.----------.- LEACHING LINE [ ) No. of Lines ................_-.- Lengfih of each linea---- .:- =-"-----T --Length -----.:.------- 'D' Box--.....-. - Type Filter Material........ ...__ .....Depth Filter Material...........................-............ ............_-----. Distance to nearest: Well----------------; -........Foundation...-.........--.........._ Property Line------------- 45EEPAGE NT [ } Depth..,. .......Diameter------------ ...Number--- ---------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth---------------- ---------•-------- . --..Rock Size--- .........----- . --------•--------- Distance to nearest: Well-------------------..............._.....-.Foundation:....._-...--............Prop, Line..........--....-_..-....... REPAtR/A DDITION {Prev. Sanitation Permit#----------------------------------- ---------------Date-------:---------- ___ ......-.-;,,-----.----} Se tic Tank [specify Requirements).--- - - ..:------- ------------- --. ....--...... -----------.-...... Disposal Field (Specify Requirements[ .----.---... --------- -------------- D_•-------: _... ............. " = (brow existing and required addition on reverse side) I 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 licensed 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 By Title ' il ' r ( f othe an owner) F R D ARTMEN U NLY i APPLICATION ACCEPTED BY-------- - f Vic-* -----_--- DATE F .. ..7 .-- 5 DIVISION OF LAND NUMBER....._..._ ......DATE - ------------ --• - - --�- .ADDITIONAL COMMENTS.... ----------------- -------•-------•----------------------- - .... --------------.....--------- -- ------- --------------------------------------------- ------------ --- Final inspection by:------ ..Date. STC eH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT fat 21677 Rev. 7176 3M