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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Ivc :........ ..... .... .... 7 �� ..._..... (Complete in Triplicate) Permit N8. .....- " .... .:.. .................... .......................... .:........ ....................... This Permit Expires I Year From Date issued Date Issued ...._. 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: / ' w� JOB ADDRESS LOCATION ... ..._ . ' " CENSUS TRACT Owner's Name .............. .. ._ .. �. ........ :...._ .: .• .... _ •---...... Phone .. Address ......................f1 ...._ � ��` r_. ty . ._..._............. Contractor's Name n _ _ ✓ Phone ._ . . ...--- ... Installation will serve: -'Residence®'Apartment House❑ Commercial ❑Trailer Court ❑ r Motel ❑ Other .....................� - _----_-- Number of living units_ _.-P.—Number of bedrooms -.....Garbage Grinder .: .,__..... Lot Size�O--- • '.. Water Supply: Public System and name -----------------------------•--.....__....._..-----------....:-•-----------------..._......--••---•..._.......Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑:Sandy Loom ❑ 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[ ] Siae------------------------------------------------ Liquid Depth .......................... Capacity ____________________ Type ..__........ ....... Material........-------------- No. Compartments ...................... Distance to nearest: Well ---------•--........................1=oundai`iort' =.: ... Prop. Line ----.....--.--........ LEACHING LINE [ j No. of Lines .....------------<...... Length of each line..................---------. Total Length ........................... :'D' Box ............ Type Filter Material ....................Depth Filter Material ..............._........_._..........._..- . Distance to nearest: Well ........................ Foundation ..._.................... ;Property Line ........................ SEEPAGE PIT [ ) Depth Diameter ................ Number -------------_---------... Rock Filled Yes ❑ No 0 Water Table Depth .......Rock Size ,-Distance to nearest: Well ........................................Foundation .._.....___ ...... Prop. Line ............ ......... REPAIR/ADDITION(Prev. Sanitation Permit# .................... •--------------- Date .. ...._...._..._ ....-...1 Septic Tank 1Specify Requirements) ...._._ -'...........:........ p ' ...... ... f Disposal Field {Specify Regwrements) .............. /---- ------•••••-•--------- ................................... --._......................................._------------------ -•-.........-----------••---------....... .... .... (Draw existing and required addition on reverse side) I hereby 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. 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 f as to become subject to Workman'i Compensation laws of-California." Signed ----a --- i .........- .. ~' r _.. ..... ........... -............. Owner Tle .................� _ r .BY 9e.� (if other than owner) D§WRTMENT_UAX16NLY 1 APPLICATION ACCEPTED BY ............... ..I.. ......... ...............-------••---•---- ----*.........._...-----.•..... DATE ...._._...l/ .."7 r----BUILDING ..PERMIT ISSUED • :.................... .,.......... .. ADDITIONALCOMMENTS .................... .............................................. ................ --........ ---•--•-•--•••..:_............. ............................ k ........................... .....-.........................................._....-••--•----- a.. -• •--•- ....... ... . __. •--•.............. . !-----_---------- :::::: � �.. =•-•- ....------•............... ....... .... ...... ....... ~.......................1,.._........... --- ._ ... ...... I Final Inspection by .................................................Date ...x ...::1 , 7 SAN JOAQUIN L AL HEALTH DISTRICT 7172 3 �14