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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 7 Z 3 - -------- ----------------------------------- ------ (Complete in Triplicate) f -- Date issued __._ --- ------- - - This Permit Expires � Year Froin Date issued �. 4 ------------- p _ "for a l the work Application is hereby made to the on compliance lion Local lthDi trice ordinance Nom549 and existing Rulestalnd Regulations:t to construct an described. This application ism p =-----CENSUS TRACT JOB ADDRESS/LOCATION .------ Phone Owner's Name ---------- .e ' City - - - _-, ---- ----------------------------- Address ----- --------- --- --------------------- IR�ense #c�- Phone Contractor's Name ----- __.- '�'�`="��-"" --"- ---- -- !_' Installation will serve: Residence;krApartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑Other -------------------------------------- --- �'�' s __Garba a Grinder' Lot Size ---�-�`----�-�-�--- --- Number of.living units:--"/-- Number of bedrooms ---_ __-- ~ ._ ) y Private ❑ a ri-_._( -- ----- Water Supply: Public System and name ___�-- -- ------- - Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sand Loam Clay Loam_❑ Hardpan F1 Adobe Fill Material ------------ if yes,type ---------------------------- buildings, etc. must be placed on reverse side.) (Plot plan, showing size of lot, location of system in relation to wells, N NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) '[ ] GFX f5` -SizeLiquid Depth "---------------"--------- PACKAGE TREATMENT [ I SEPTIC TANKN Capacity Type Material No. Compartments ------ •-------- ,11 Distance to nearest: Well ------------------------------------Foundation ----------------- Prop. Line ----------------------- RI el LEACHING LINE No, of Lines -- ----/---_-------------- Length of each line-------- --a___-- ------ Total Length :------ ----------- 'D' Box __ a Filter Material .-� ----Depth Filter Material _- ---- ------ Type r Property Line<r Distance to nearest: Well ✓Q___W Foundation ' _ Diameter �{.�--�! Number _"__ _"" Rock Filled ',Yes r� No C]SEEPAGE PIT Depth --�=�------- N .k a n - -------Rock Size --- ' - t Water Table Depth ------�- ----��- ------- --------------- `` r 4. Distance to nearest: Well _A1 Foundation _DC7 -=-.---- Prop. Line ... ........... . REPAIR/ADDITION(Prev. Sanitation ----------------------------------- Date ---------------- ------------------) - Permit# -------- ------------------- ------------------------------------------- Septic Tank (Specify Requirements) r , i Disposal Field (Specify Requirements) ---.--- � -------"-- --- c -------- ------ - - - - - ------------- -- - ng an -------------- (Draw exist id required addition on reverse si d e 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 licpn- ( sed agents signature certifies the following: for which this permit is issued, I shall not employ any person in such manner "I certify that in the performance of the work as to become subject to Workman's Compensation laws of California." Signed - = -------------------- ---- Owner f ? Title ---- - (If other than owner) FOR PEPARTMENT USE ONLY 4 DATE ------------------ APPLICATION ACCEPTED BY ---C-----------'----I------- -- - ------------------ ------ - - - -----------------=---------------- DAT ---------------- ---- ------------------------------- ------ BUILDING PERMIT ISSUED --------------------- ----- ------------------- ADDITIONALCOMMENTS --------------------------------------------------------�---------------- � - ----- ------ ------- ----------------- -- - -------- - ---- ------- -------- .- ------ ------- ----- ----- -- ----------------- -- -=-------- Date -------- ----------------------------------- Final Inspection b - ------ --------------------------- .. SAN JOAQUIN LOCAL HEALTH DISTRICT lam,, r_ u 0 1-'AS Rev. 5M.