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FOR OFFICE USE: APPLICATION FOR SANITATION MMI!T Permit No. - Q� 1Complete in Triplicate) y� .--------- ......................................................... . This Permit Expires 1 Year From Date Issued Date Issued l-_`l:.'76_ 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 Rules and Regulations: JOB ADDRESS/LOCATION -� CENSUS TRACT -•---.---... ............................. . ......._.... . ..........._ ................-........ . Owner's Name ""----- --• . .... Phone Address � .-----•---... _ ..... .city Contractor's Name ---- ---- ----- -- ,-y-_.�.�._ .. - . .� __..License # . � — Phone .................... �} Installation will serve: Residence[Apartment Housefl Commercial QTraller Court C] Motel Q Other...... -- ' Number of living units:__._.--._.. Number of bedrooms ..... Grinder ............ Lot Size ....:....................... . ............. Water Supply: Public System and name . .: --------.........•----•.................................----......................_.............. . .........Private Character of soil to o depth of 3 feet: Sand Q Silt Q Clay Q Peat Q Sandy Loam Clay Loam Hardpan(] Adobe ❑ Fill Material ............ If yes,type............... ............ IN� (P.lot plan, 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 seep ge pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK Siae.�� ` ...�.L.r..��,�. .._.... Liquid Depth .::. ............ Capacityfftone - --- Type _ .._. . - .. Material---rte-- No. CompartmentsDistance. est: Well .T --------- .....-......Foundation ...... Prop. Line ..2r..:._.. LEACHING LINE [►I No. of Lines 2. Type ......_-- Length o each line.:._;�C�. Total Length ...s .S d.-�.. 'D' Box ...../",-. T e Filter Material .......�.A.I.Depth Fi ter Material ..._. .9•.`. ...................... T^ Distance to nearest: Wel! .....�: 3f1_. Foundation ..._.I Q.. - ..... Property Line ...5t? .... SEEPAGE PIT [ J Depth -------------------- Diameter ................ WMber...--------..-.._...------_-- Rock Filled Yea Q No IL] Water Table Depth .... ..........Rock,Siie•- Distance to nearest: Well-:::..•=--._ �...:.....::..F`.._Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prey. Sanitation Permit# ....... `--..........• ---------------- Date -------__- ----------------------j Septic Tank {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 bone in accordance with San .Joaquin County Ordinances, State Laws,--and Rules and Regulations of the San .Joaquin Local Health:District. Honre_: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 manner as to become subject to Workman's Compensation laws of California." Signed .................................... Owner BY -.._--------------••-------------------..._ . 7itie (if other than owner) -- FORD ARTMENT USE ONLY APPLICATION ACCEPTED BY ----------- DATE BUILDINGPERMIT ISSUED ----------------------------------- --------------- --------------- - --- ------ ....DATE ...._.... .............. ................ ADDITIONAL COMMENTS ------------ ................ _... ------- I------ •--- - - -•---•- --- . Final Inspection by: - --------- • ..._Date �� •... , ------- EH 13 2L 1-6 ii Rev. 5 SAKI JOAQUIN LOCAL HEALTH DISTRICT , 8/7h 3M