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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _.......1.....................•-•-•............ Permit No. a (Complete in Triplicate) ................... ................. .. Date Issued� � -=7J. .....................I.................... " " This Permit Expires I Year From 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 made in compliance with County Ordinance No. 549 and existing Rales and Regulationst a JOB ADDRESS/LOCATION ............ .' �,/�........ ......./ ,�. --.....................CENSUS TRACT ...... ............ Owner's Name ........:........ .. . �..__._ /_ .. ._._....................._...._.........,.... ^._ Phone..f...... ..? Address .......: it --- city ..... ._...... c c� Contractor's Name ---- ---------------------�-��-----�-`-^--'`-'`'-"-`� ----�-�------------•------------License # - 1..�.��..._ Phone .------�--- Installation will serve: Residence �rtment House 0 Commercial OTrailer Court Motel ❑Other ------- '•------•---•-•---•..__.....•-•-•• t Number of living units:-.--:- ----- Number of,bedrooms .3-------Garbage Grinder-- 4;�-! ...... Water Supply: Public System and name ..__.___ ...Private "" ------.._.....-----•--------..._.... Character of soil to a depth of 3 feet: Sand Silt❑ Clay .0 Peat❑ Sandy Loam 0 Clay Loam 0 Hardpan ❑ Adobe 0 Fill Material If yes,type ..:............ ... (Plot pian, 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,) I PACKAGE.TREATMENT T (.,) SEPTIC TANK f J Size.................................................. Liquid Depth ........................... Capacity ..... Type .................... Material---- No. Compartments --.....--_--_.-_..�G p tY -•----•---...-• YP p S � Distance to nearest: Weil :--..._:=_ ••Foundation ;---------------. Prop. Line .. LEACHING LINE ( J No. of Lines ------- --------- -`------- Lgth of each line---------�----`='----::_ .-.Tota1•rLength b .------.._.................. 'D' Box - Type Filter Material ....................Depth Filter Material ........................................ i Distance to nearest: Well ....................... Foundation .j Property Line SEEPAGE PIT j ). Depth Diameter ...... ......... Number ..--•-;..................... Rock Filled Yes ❑ No t Water Table Depth -•-----------•------- --- ........Rock Size -------------------------------- / 4: r± I `balance to nearest: Well .......................................Foundation .................... Prop. Line ................ ._ _-- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ........................... Septic Tank {Specify Requirements} {.... ............. ............. --•••••---•--•--•-••-•••... ......I............ sv . Disposal p l Field (Specify Requirements) ................•---..... ...... -........................ n ----------------------------------------------------- --------- .......•--- ..... ------------------------------------------------------------------ --------------------------------- (Draw existing and required addition on reverse side) I Sereby 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. Horne owner or licen- sed agents-sigrnature testifies the fottowiK-9 "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner r as to become subject to Workman's Compensation laws of California." Signed --------------- -------------------- -- --------- Owner BY ----------------------- . ...... . . .----------------------------------- ------------•----------•---------- TitleG(if than owner) FOR DEPARTMENT USE ONLY � - - DATE .. ._.. E APPLICATION ACCEPTE57 D BY ____ _. .......... .. ..... / BUILDING PERMIT ISSUED ---------------- ...... .....-•--••... -------_DATE ................................. }. ADDITIONAL COMMENTS --------------------------------- -• -------. . --- ..----------------------------.----------_-.................. •---- r = ............................... ----- ---- ---- ----- ---I=inal Inspection bDate y.. _. p Y :.. =- -----• -�------ -----------•- ------- I , 3 2!t 1--613 rev. 5�l SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M