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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. _.�5................. --� (Complete in Triplicate) -----------I--------- --------•- S ------ This Permit Expires 1 Year From bat*Issued Date Issued _.�_.. 7..... i 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 madeincompliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .......... ../.. .� ...- ._-- ENSUS TRACT ........................... Owner's Name ........ ...................................... ' ..-.--��.0._!7_A�._.:�.G'..._._.,.�1!.Z.O---�-•------------------- ....---------------------Phone /1k!_ CL. A,.A-. ----------•---.-_.:.---. City ----------A. -- --- - -.;.. Contractor's Name :.-.....P .. ............:.......-.............................. .......... License # .. .......... phone .......................... Installation will serve: Residence [B portment House I—] Commercial []Trailer Court ❑ Motel ❑Other ........ .......• --- ......-•---=---••-•-- ti , Number of living units:.... Number of bedrooms ------------Garbage Grinder .__...._ lot Size.........................................:... Water Supply: Public System and name'-.-.,.........-..................... --_._...-_-;---_----------------------------------------_----:--__-Private ❑� Character of soil to a depth of 3 feet. Sand W-, Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ ` Hardpa ' Adobe n❑ Fill Material ....... -_-- If yes, type ------------------ (Plot 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 seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT ( ] SEPTIC TANK p I ] Liquid Depth . Size------------------ . ..---- •- -. ....._ .........._._. .G Capacity :. . Type -------------------- Material..- ......_.....:_... No. Compartments ................ 00 Distance to nearest: Well .. .. ...-..:. __Foundation .- .__- Prop. Line .................. LEACHING LINE: •...[ ] Do.B%lines T' a Filter Material ___________________:De Depth Filt .�.- � •� Notal Length :..- Length .of each line .. _._.. yP p er Material _..... ...... F Distance to nearest: Well .._--:._ foundation ------ Property line -------------------------- SEEPAGE PIT [ { Depth: :-- Diameter ________________ Number : ....,':.....:...__-.._...__ Rock Filled Yes C] No Q Table Distance onearest. Well -.:-_--__ Foundation Pro Line ................ Depth Rock Size :.............•'--.. - _.- REPAIR/ADDITION(Prev. Sanitation Permit# ......... _____ _____ _________•.... Dote ------- ...................... Septic Tank 15pecify Requirements)- -- ------ ; I _. Disposal Field (Specify Requirements) ---7d.- --- . ...-. r 3 ------------- - -= --------- �''�..._ ��X_.-/-� ��.... ........... ._.. .. --._'._.....-- I. ....--__•_-•_._...-!_..._ __••-. ........................ ....•----------------------_-------- ............................ ............................... .-..-.-. (Draw existing and required addition on reverse side) I hereby certify that 1 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. 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .... ..............:................. r- -• -- •--- --------------........ •. Owner By --- ...• -- ......... title IE {I other-than owne } } r FOR DEPARTMENT USE ONLY ADPL TION ACCEPTED BY ......._.. ATE BUIL NG PERMIT ISSUED ............ ........... .. __ ._. _. .......DATE •. • -• ADDITIONAL COMMENTS ------ ------------------------- ---------------------------------........-------... ,................................-.......................... .:...._.... ------•------------------------ ••---- --------------------- -------- •. ............ --...... ..----- ------ .- ------ -- ---- ---- ---I——------7------------------------- ..................•----------.....--- Final Inspection by: L �•�r4.-Gs�i_� .. .----Date .. �� J ... SAN JOAQUIN LOCAL HEALTH DISTRICT