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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .......... ... .......................................... .'."�.. ._ (Complete in Triplicate) Permit No, .S. This Permit Expires 1 Year From Date Issued Date Issued ll an�]s 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 Ordinar?ce No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION 3. CENSUS CENSUS TRACT .......................... .. W . Owner's Name ...... ........... . .. . ......................... .... •--Phone Address --•.................Ip /C ------... -- / City ... ..... - •------- ........ ----------•---•-• Contractor's Name ' .... .:_.....i.icense # _in. Phone .............................. Installation will serve: Residence dApartment House Commercial '❑Trailer Court i❑ Motel ❑Other ............................................ Number of living units.--...,/.._,- Number of bedrooms _._..Garbage Grinder ..... Lot Size ............................................ Water Supply: Public System and name .------------------------------------------------------------------------------------------- ---------.-Private 2 Character of soil to a depth of 3 feet: a❑ Silt[J ❑ Peat 0 Sandy Loam ❑ Clay Loam ❑ HardpanAdaMateral ... 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: INo septic tank or seepage pit permitted if public sewer is available within 200 feet) PACKAGE TREATMENT SEPTIC TANK Size.A�ZP X_� !�. .............[ ] � ] - --•-- • -• - - - -- Liquid Depth ----V-----•............. Capacity .I- p.?'?--_-• Typ.EErrlr.��c.. Material---�#--J--....... No. Compartments ....�............ OQ t �- Distance to nearest: Well ........J16...................Foundation .......1.4........ Prop. Line ...._.................-0 LEACHING LINE [►'f No. of Lines ..__...�.............. Length of each line.___._.__.. ... Total Length .._. 4 C1' Box ...f:774.... Type Filter Material _.��. ...Depth Fester Material --------/.4........................... lie :... Distance to nearest: Well ........&P........ Foundation ..... ......... Property Line l Depth .---f.la..�_--- Tet gNumber ----------. C....____-. .- Rock Filled Yes [E" No ❑ Water Table Depth •-----.. .......................Rock Size ---- �� ..._.. ..�...�:'._....... Distance to nearest: Well ............... ......Foundation Prop. Line ...!C-./ ............ REPAIR/ADDITION{Prev. Sanitation'Permit# _.. ........................................ Date __________________________________j Septic Tank (Specify Requirements) ..-------____..................................... .....•-----•...----- . Disposal Field (Specify Requirements) ._.. ®--_- •_-_ - .........:'w"`......2' ......._ _.... --------•-•----------------------------------------------•----•--..._....._..._..._..............-_-..__.........._...._._.._..__._._.,..... ..... (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. Hoene 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 mannan as to become subject to Workman's Compensation laws of California." Signed ...----•........................ Owner By ..... ........................ •-------•- --. 0!�.. __.. Title ... ._. - --- _. .�^J ({f other than owner) fi_ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...._,!�` - �- _ ••---•...................•--- .......................... DATE ...... BUILDING PERMIT ISSUED ................ ...---......................_._.....__._...............------....DATir ...................... ADDITIONALCOMMENTS ................ ................................................................................................................................... ----........................---....---.....--..._......-•-------=•_-•---•-..._...._..............._.................._..__......-•-----••-----............----....----••---...................__...._.. /i" , Final Inspection by: ��1' !: 'it^! _--' ' Date T r .................... SAN JOAQUIN LOCAL HEALTH DISTRICT �1 E. H.13 241-'68 Rev. 5M 7172 3 m