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FOR OFFlrE USE: - APPLICATION FOR., SANITATION PERMIT �u Permit No: -_7 ----- (Complete in Triplicate) -�-� ---------------------------------------------------------- � This Permit Expires 1 Year From Date issued Date Issued __/..a------------- Application _` ----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 nd Rules and Regulations: JOB ADDRESS/LO- TION �� = /�I US TRACT --- Owner's Name u -� mL ------- Phone , - Address . `7Q r< r ,t�--- - City --------------------------------•--- Contractor's Name ... .......C..... -'�-- � ---.License #.2 Phone�,�� : - Installation will serve: y ResidenceApartment ousel❑ Commercial :❑Trailer Court ;❑ Motel ❑Other - ------------------------------------------ Number of living units:-----/--- Number of be ooms --/-----Garbage rinder _- - . k --- Water g --. Lot Size -----�- ----------- --�---- ------- Water Supply: Public System and name ------ --. __._. G�- .--------------------------------------------•--------.Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe 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{ ��---- -'Liquid Depth __-__---_ -- ----------------------------------------- - ------------ Capacity - ------------------ Type -------------------- Material---------- ---__ ----- No. Compartments Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- ' LEACHING LINE [ No. of Lines � __------------ ING LINE No. of Lin es ---/------- --------- Length of each line------op"'a-- Total Length ----,� f Length of each line t 'D' Box-- �-.- Type Filter Material ---_--Depth .Filter Material __ - r-------------------------•- Distance to nearest: Well Foundation ------- Property Line --- SEEPAGE PIT f Depth -- _f__- Diameter -s - ----- Number ........ Rock Filled Yes , `� No ❑ 7l Water Table I Depth --------_��f �� ' _ ------- - - --------------Rock Size -- - Distance to nearest: Well ---- - t Foundation -__ / '`,""'t- �GY-- ---- Prop. Line ---------------•--•--- REPAIR/ADDITION(Prev. Sonication Permit# -----------------------------------------=-- Date ------•----.-----------------_---- Septic Tank (Specify Requirements) ---- ------------------------ .A--- ----------------------------------- - ------------ • `- - ----- Disposal Field {Specify Requirements) ------- ----_ -_-- --- '_-------��-- ------ -----„ . ---------------------- ` ------------------------------------- --- ------ - ----------------------'--------------------------------;----- y (Draw existing and required addition onreverseside) T-----------_ _ I hereby certify that I have prepared this application and that the work-will be done in accordance with SonJoaquin 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: 1 t "1 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 , ..J # - --------------- ---- r By ------------------------------ -- 1 - c.--------Title ------- A -------- -------------------- (if other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ------- ------------------------------------------------------------------ DATE Z-------- BUILDING PERMIT ISSUED ---------------- - ------------------- -DATE --------- ADDITIONAL',COMMENTS --------- .........ac ` - - -- ---=----------- -------------------------------------------------"' - ' ----------------------5__---_---_______-----.- -------------------------------------------------------------------------------------------------------------------------------- --------------------------- -------------------"-- R Final Ins ection b Q p y-. ---_-- - - Date --- 3�J�------ ------ 5AN JOAQUIN LOCAL HEALTH DISTRICT _ E. H. 9 1-'S8 Rev. 5M