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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...................................•--.......-------:...: . 7��:7� f (Complete In Triplicate) Permit No ...._ This Permit Expires t Year from Dat*Ilssued Date Issued - - F � 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 withunty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LO TION .:...._...__� n.----:.............. •---•- 1 F .................................... .......CENSUS TRACT ....._...._...__.......... Owner's Name .............. P .....j-•.............••_•---.....-------:..._.......------...Phone - ------• A.. 11 • •--•-+-�^A•• �_.._-.:. Address . _........... ....... ------.._•••... .........• . ...... 15�Contractor's Name --- ------- ........License # � --- Phone Installation will serve: Residence:;�partment - _ - House fl Commercial OTroller Court ❑ Motel ❑Other------=----------•......_g:......_:......:_ Number of living units:_.. .... Number of bedrooms ---3.....Garba e Grindery,•��._ Lot Size ....... . Water Supply: Public System and name ...Private ��— Character of soil to a depth of 3 feet: Sand b Silt❑ Clay 0 Peat❑ Sandy Loam ❑ Clay Loam ❑ vE Hardpan p Adobe I❑ Fill Materlal ............ if yes,type............... ..::.... (Plot pian, showing size of lot, location of systeri�?n'relation to wells, buildings, etc. must-,be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage`01t permitted If public sewer is available Within 200 feet,) i PACKAGE TREATMENT F ] SEPTIC TANK[ ] ize . Liquid Depth Capacity P tY -------••----------- Type ...............}.. Material...................... No. Compartments ...................... Distance.to nearest: Well ................. ..............foundation ....................... Prop. Line --._____....:.........� LEACHING LINE [ j No. of Lines - •---------------•------- length of each line..--------••-...---•-•------ Total Length .--•--.. ............ V Sox ------------ Type Filter Material --------------------Depth .Filter Material .................................. Distance to nearest: Well ................:....... Foundation ..--_-----------....... Property Line .......................%00,40 SEEPAGE PIT ( I I Depth _ Diameter Nurt►ber ................. !tock Filled Yes ❑ No Water Table Depth9 . _::Rock Size --•••-.. -. ----------••-•--••------ Distance to nearest: Well ................................... - Foundation ...... Prop. Line ...................... REPAIR/ADDITION Prev. Sanitation Permit# ....... Ddte¢ Septic Tank (Specify Requirements) s Q.t ..............`..----:..•••. ------------------•--,...................................�................... Disposal eld (S cify Requirements) - ------------•• --------------•- ----------------••----------------- ------ ....-.................._:.................. ........--................ .......................... (Draw existing and required additicih on revorse 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 Safi 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,-1{'shall not employ any person in such manner as to become subjezt to Workman's Compensation laws of California." x. Signed!..:_'__ _ x_ Owner _ ____ ___.._. _--__-_--..____-___-•___._-------__ Oi �.• I er than owner! _.. ._ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.......... ---._.. s i DATE ...........�0... � --------------- ----------------• ------- BUILDING PERMIT ISSUED .. DATE ------------------- ADDITIONAL CO MI: TS . .: -----_ �✓ = ------------------------•------------------------------...__-. ----- ----------- .................................................-------...---...._..... ............ ... ------------------------------------------------------------------- Final Inspection by: .-_-.--- _----.--_Date ..... - - EH 13 2 1'�' '�• SAN JOAQUIN LOCAL HEALTH DISTRICT - ` ''$/74 3M 1