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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit No.... .................. ............. This Permit Expires i Year From Date Issued Date Issued------ w - Application is hereby made to.the San Joaquin Local Health District fora permit to construct and install the work herein describ This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: e JOB ADDRESS/LOCATION... -- -------------CENSUS TRACT-- .------------------ Owner's Name..- .._.- r ---- ---- - --------------------- -- Phone __...p..--.-.-.- Address.-----...__. " "._�-v'--- --- --- - - ----- -----• ---.Cit --•--... -- -- y--- ----------.--...-.-----.-- Zi .-- -•....-- --.. Contractor's Name.---- - Phone-- .-- - - 7 - -- - - � .License #-. .Q � - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mo el ❑ Other--. ...... - - ' �- i Number of living units:--.- Number of bedroorris.�" GYbagF Grinder:-- .--'La'Size."t.�P. - + - ..- --y--� Water Supply: Public System and name........-- --.- ------ -� --------- ---------•------ Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam I 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 TANKI�, �( ~ ( ) Size _'l''/1.- �- - x - 401...................Liquid Qepth.-... Capacity---/AaA).(?t--Type Material--. .. . - No. Compartments_... istan ce to nearest: W' �e'• ---Foundation...-_-.f 49--.... _. ..Prop. Line----- LEACHING LINE No. of'Lines ............ .�^. ~ of each line.--.-----.��-------._-- Total Length 'D' Box__. .. _.Type Filter Material---._-. _ --Depth Filter Material--.--_ ista ce to nearest: We'll----- _- -�....- ----.Foundation----.. '- ------------- _Property Line...-....................... SEEPAGE PIT ( ept Diameter---------------'.._ Number..- ---- ' Rock Filled Yes Nr.- Water Table Depth----- ------------------ -.-- - --.-- ........ Rock Size-... �..aii``}�� ��' --------------------- Distance ----- --Distance to,nearest: Well.- '-..._ --- Foundation_--......................Prop. Line---...-.-------- -.- PAIR/ADDITION (Prev. Sanitation Permit#--------------- ------........... ...............Date.__------.---.-.- ) Septic Tank (Specify Requirements)._.._.._._- _„-, , -,- -w - ...... ... ......... ....... : Disposal Field (Specify Requirements)....._............. -------------------- -------------------------------- ""r .-.--•-------•---..... -------------- ------------------------------ ...... -- ---- --- ---- (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 licensed agents signature certifies the following:' I "I certify that in the performance of the work for which this per is issued, I shall not employ any person in such manner as' to become subject to Workman's Compensation laws of California.” Signed----.. " ' Owner - - . BY . -- .------ Title ( other:than o ner) FOR D PARTME USA ONLY APPLICATION ACCEPTED BY-•---- DIVISION OF LAND NUMI3EDATE ..-. -Ti...7 ..................... -- R ...._ - --- ------ ------- ----- ---- ------ ----------------- DATE. ADDITIONAL COMMENTS... o.� f �t1t/.... .......... ..... .___...... ........... . .. ...._...:...... ...... ..._... -------- ----------- ------------------------- --- -- --- •.-.--..-.-.----- ------.... . Final Inspection by:...._. l - -�- - - ----- ----...gate-- - EH is sa SAN JOAQUIN LOCAL HEALTH DISTRICT F6s 21677 Rev. 7176 sen