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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ................ ..................... .............. This Permit Expires 1 Year From Date Issued Date Issued 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 ...��c `m-_...� . - ...gy - = . .�.� � Phone .. _.. . -- City .. . : .. . . Contractor's Name .. _ l ,.-+� .--- . . � �"' Phone ------ ....................... - - ..:�_ ..._..:- - --- ----- - ---- --�-License.# ...1�eS' 3.�_ Installation will serve: Residence❑Apartmerit Hduse 0 Commercial ❑Trailer Court :❑ 1 Motel ❑ Other .. -� _:_ - ------- Number -Number of living units _. ..... Number of bedrooms- .__.✓-_.._.Garbage Grinder ..._ ........ Lot Size :.... -----------------jf-.-_----.-..'_. Water Supply: Public System and name -............. ....... ............`------------------------ __ .......__....:..__......Private ®� Character of soil to a depth of 3 feet: Sand Silt E] Clay ❑' Peat❑ Sandy Loam 0lay Loam ❑ � - - p ❑ ❑ . Hardpan Adobe Fill Materia! _.i_._, .'_. If yes;type _._:.............. k - - {Plot plan, showing size of lot, loc'otion Of systern in •relafion .to_wells',-.buildings, 'etc..:mutt be placed. on'reverse side:} 1 NEW INSTALLATION: (No septic tank or seep ge•pit permitted if.pvbiic s6'wef: is avoilable-within 200 feet,) ; PACKAGE TREATMENT SEPTIC TANK, Size'�� .� ;9 ................ Liquid Depth ..: . _.....__.......f. t51 � 7 , CapacityType Material__ .+G� .... .No. Compartments ' . ........._. x r ne`arest. We I ... ne Foundation' .........1 . Prop ,Line ----�'...... .......'. e Total Length --. --------------- LEACHING LINE Noof tines Lengthofeai 'D` Boz --.� Type Filter Mdterial '; .:Depth Filter Material fir'.."............. ..... i Distance to nearest: Well ......�{7Q�- Foundation, �. . _...'TProperty Line .......... T_ SEEPAGE PIT [ ) Depth Diameter led Yes ❑ No i❑ 0 .�. Number _ : Rock Filled i ? WaterTableDepth:. .. .........Rock Size ..... :..... .... . ....... i _.�._ : Distance tos;nearest::Well •.. ...� :---.--._ ..� f Foynd,ation .-._.......:.... .:. -Prtip. Line --- REPAIR/ADDITION(Prev. Sanitation,Permit# --- , .:... -- ---- -- - ;Date ------ ........ Septic Tank (Specify Requirements) ........ --------- ------------ - ------ Disposal --Disposal Field (Specify Requirements) ------ ................. ... ..... A.. .._.. _. --------- - t - -------.: .-- ..-•-- - - .................. 4 F --------------- (Draw existing and required addition on reverse side) hereby certify that I have prepared this application and than 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 Galifomia." Signed .... ... ...... ------ Owner By .... . ......... ........... Title _.. . ..... ............................ (If other than owner) I FOR DEPARTMENT USE ONLY -- -. - APPLICATION ACCEPTED BY ...:......... .. ..-. ...- ------ -. •--...=_... � -.-_-... DATE BUILDING PERMIT ISSUED -------------------- ------ ----------- ..........DATE .' ...---......---------•---..__..._.._... ADDITIONALCOMMENTS _..... - ...---..._....._:......:......:.......................... ....................................... .......................... . : . - - - _g.1.�........................ . - . .--- ----- --•-------- ..-. Finai Inspection by: ........ .........................- - ... ..... i SAN JOAQUIN LOCAL HEALTH, DISTRICT c u 13 24,k •tea o_., cAA .,. 7/793M