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FOR OFFICE USE: -� APPLICATION FOR SANITATION PERMIT �..7�a .............. Permit No. .y...: ......... (Complete in Triplicate) ....................... This Permit Expires I Year From Date Issued bate 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 �jOrdinance �No. 5499hand existing Rules and Regulations: Ilo 1 �`~ .S ` �P1� Lt7? .:.....CENSUS TRACT . JOB ADIJRESS/LOCATIO _, ____.- . . ._ f�.�... Owner's Name ........-.. . e.............. ----•-- Phone ..... .. Address --..--.... 12.1... ............ .........................City.... `_.... ................�.................•..... Contractor's Name ........ T..�.--/............. ....................................License # ............,---•---_- Phone ........ Installation will serve: Residence partment House❑ Commercial ❑Trailer Court Motel ❑Other ............................................ Number of living units:..--.1..--- Number of bedrooms .........Garbage Grinder ------------ Lot Size ....1 X- 7.. .............. Water Supply: Public System and name ......... ............ -•••..................•---•---•--••-••---•.-...................-•••••••••-•----•••Private Character of soil to a depth of 3 feet: Sand b _ Silt❑ Clay ❑ Peat❑ Sandy Loam Cloy Loam ❑ Hardpan ❑ Adobe.l] 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 If public sewer is available within.200 feet,) PACKAGE TREATMENT ) ] SEPTIC TANK Size................................................ Liquid Depth ............--_........... Capacity/9.00......... Type Material Cv-t .... No. Compartments Distance to nearest: Well .--- Q..........:.... ____Foundation -------.... Prop. Line .. ......... J LEACHING LINE No. -af Lines _------ Length of each line._-.. .- � l•� -----z=..--- g 7..... .............. Total Length --------•---• , b` Box ..... Type Filter Materia( S •! �Sx�tDepth Filter Material __- ..........................V Distance tonearest: Well � rtYLine �5 _ ...... .......... e . ................ SEEPAGE PIT [ Depth 1:5/...._.... Diameter . ......... Number -------eZ=_. ._..... Rock Filled Yesiff--No ❑C Water Table Depth D • .-.__._..Rotk Size Distance to nearest: Well ....................-......Foundation .... Prop. line ............. REPAIR/ADDITION(Prev. Sanitation Permit# •........................................... Dote .................................. SepticTank (Specify Requirements) --------•--------•--------------•-------------------------------------•--••........------.... ..........................._.,............... Disposal Field (Specify Requirements) -------------------- -- ----------------------------•------------_.,,_-------._--•-----•----------- _................... ----... -•---------------------------------- ...................-.......... ............. --------------------------- -----------................................................................................................................................................................... (Draw 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 licen- sed agents signature certifies the following: "I certify that in th rformance of t" work for-which this-permit is issued, I shall not employ any person in such manner as to becom j t W am satin larnis of California." Signed .... ......_. Owner �4 r k4 B _. Title (If;other than owner) _. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -..':...... y � _._. - - ----=-------------•-.-...-------...---------•--.:..---•---.............._..._, DATE ....�'�..�-._. , rl`' .._._....--- _ BUILDING PERMIT ISSUED ........._%4-.... ......--•---•---•- ............................•---DATE ........................................_.. ADDITIONAL COMMENTS F " . ......... t ....................--.......----------I—...............;.:- ........... ................................................................................. ...............•-----.... ............. •-----...............---•••. ...._..----••. ------------------ .,/.? Final Inspection 6fi y '> - P Y' -` --.Date ----��••- SAN_JOAQUIN -LOCAL HEALTH DISTRICT