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' FOR OFFICE USE: "` ;3 rs - _APPLICATION FOR SANITATION PERMIT _ - (Complete in Triplicate) Permit No. ......... � ...... ......................................................... /a a moi` E This Permit Expires i Year From Date Issued Date Issued .14........... ------------------------------ Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in co pliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .._ Qt t1 •\ ° rL�._---......�fv- CENSUS TRACE .:.............:......:..:: Owners Name C '''�.. ..... r =f� t .............:.:. ..:•- _Phone . . -..5 � € Address � �- '!- f F ----� ....... :..--- ::_.City - r z _ __:`:.................................. .......... ! Contractor's Name - _:. Phone ...., f1 Installation will serve: ResidenceApartment Houseo,Commercial ❑Trailer Court 0 Motel_ ❑Other ---•-------- ............- ...... Number of living units:.....!-...-. Number of bedrooms Garbage Grinder .........;_.. lot Size .�, .l:z ...... . ; _. Water Supply: Public System and name .........................:..........��-._:..--------_----- ---- :-- Private ❑ Character of soil to a depth of 3 feet: Sand ❑. .Silt❑ Clay E] Peat❑ Sandy Loam"d Clay Loam 'Hardpan ❑ Adobe [] Fill Material _ lf'yes, type ------------ {Plot plan, showing size of lot, location, of,system; in.:relofion to.wells, buildings, etc. :must be'. placed:'on}reverse side.) i NEW INSTALLATION: (No septic tank, or seepoge:pit permitted. if public sewer is available within 200 feet,). PACKAGE TREATMENT 3 SEPTIC TANK Size ' _ _____________ Liquid Depth . � ............. Capacity ....... Type ..... Mtateriai.� a Compartments ..�......... 4 Distance to nearest: Well f !...:.....:.........Foundation .. -Ap", .. ... Prop. linej--:�7. _. ..'. LEACH NG LINE No. of Lines _...Z..__...._::__ : Length of each line.-. Total' length .! ........ 'D' Boz I Type Filter.Material ..._:..Depth" `Filter Material ..........................:..... . Distance to nearest: Well 1`... . :._...: Foundation ..._ :....... ......' Property Depth ......' r !--- :-`_ : :_ :Ronk Milled : Yes No = SEEPAGE PIT Water Tab Pth.-��te�--:--- .•--6V�mheRoek_Size;`��_fZ'K-��•-•.-•-.- .� I Distance to nearest::Well .. .Std .... :.......:.....:.._.....Faundatibn �..r..__.:_ Prop Line REPAIR/ADDITION lPrev. Sanitation Permifi# ....•--.:-.:....... ...........:------:----. Date .................................. i I SSeptic Tank (Specify Requirements) l ----------•-------... ----.._ ...-•----•••-- -•------•-- i Disposal Field {Specify Requirements) --_-___'_ . ..................... (Drdw existing-and required addition on reverse side) F I hereby certify that I 'have prepared this application and #hav the l work will be done in accordance With-Son Joaquin County Ordinances, State Laws, and'Rules and Regulation of the San 'Joaquin Local Health.District. Home owner or Ilcen- sed agents signature certifies the following:, t ro. m ... "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 beZrn,,4 sub'ec orkMan's'Com ensation 16ws of C 1�rnia. � 9 �= -. Si ned .- --- ....0. By •._..... .. :::..::.......... Title ::: .. �... .._ . ........ ...................;..:..:.: ( other than owner. . OR DEPARTMENT USE ONLY s APPLICATION ACCEPTED ....t... :................... •-- DATE BUILDING PERMIT ISSUED ......._.:.. ..:.::. .. ..................:::.. ::..:.:...................:............. .... DATE = ADDITIONAL COMMENTS ........:................................•-- s..._........;........_.. } • ------------------------- r_____ .___-••___ .... _ .._ ........................- __ _. .... . ................ .......... .__.---- - ... F ` Final Inspection by: _._.. .. :�..... _.__...T - = Dated ' SAN .lOAQUIN°.LOCAL HEALTH DISTRICT _ ._. .. . ,__. ._ _... .._. _ _ _.. . ± r u 13 241-'AQ De.. RLA 71723 M