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_FOR OFFICE USE: APPLICATION ,FOR SANITATION PERMIT lComplete In Triplicate) Permit No. . . ........ ................................................... .. . � . . ........ I This Permit Expires 1 Year from Date issued Date issued E Application is hereby made to the San Joaquin Local Health District for a permit to constrcict and Install the worts herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: r I „ . E JOB ADDRESS/LOCATION Jht ....W_- CENSUS TRACT ff,,� Owner's Name .... ......... Phone / ................................... Address ........... _ ............ City ... ................................... Contractor's Name __-- �. .. .. . =-....i.kense #�c lr��•3� Ph ...y one ............... Installation will serve: Residence[Apartment House 0-Commercial❑Trailer Court 0 — ,..�.�. Motel'Q Other:`::-...�"r-------=-=---- -�-�:_:�:::: Number of living units:......I._.. Number of bedrooms ..3----Garbage Grinder -------- Lot Size .. ..... Water Supply: Public System and name .............. .............. Private [ — -- . . .... ........ Character of soil to a depth of 3 fee .. ... ........... t: Sand b Silt❑ Gay ❑ Peat❑ Sandy Loom Loam j] ` .Hardpan ❑ Adobe 0 Fill Material........... Ifypa,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 244 feet,) PACKAGE TREATMENT { SEPTIC TANK{ } � Size-----=----------•r------•----------........................................................ Liquid Depth .............. ........ .. Capacity -------------------- Type ':..-;.•:.`..__. _.. Material----....— -No. Compartments -----_-------.-_..-- Distance to nearest: Well '" ..__.::.:Foundation''_'�":.......:::...... Prop. Line LEACHING LINE [ ] No. of lines ------------------------ Len th of each line............................ Total Length ........................... V Box ------- Type Filter Material ....................Depth Filter Material I Distance to nearest: Well ___________________ Foundation ......_..--.... -------- Property Llne ....... ................ J SEEPAGE PIT { { Depth ..... .._-, f --------- Diameter ---•------..._-- Number -----...............•- ___-- Rock Filled fYes ❑ No ❑ i F l s � Water Table Depth ...--•-------------•-......---- Rock Size ..... `- .... =. Distance to nearest: Well -----.---_--.•--------•.......... _-Foundation .................... Prop. Line ...................... REPAIR/ADDITION#Prey. Sanitation Permit# ----------------------------- ___--- Date .................................. Septic Tank (Specify Requirements) ------................................... Disposal Field (Specify Requirements) ----Q_c_.-ziecee �� �! � ------ ...................___. -- 1 --------------------------.----------- ................... ---------._.....------••---............._...------. ---••-----------------------------••---------- ............................... .•-•-- --• {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 f County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Hone owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person In such manner as to become subject to Workman's'Compensation laws of California." Signed ------------- -----•-------------- i - --- Owner 4 By ---- •------------------------- �- �61� {If other than owner _ Title_._. .. i y FO D . ARTMENT USE ONLY APPLICATION ACCEPTED BY ...... •----------------- --• ------ DATE BUILDING PERMIT ISSUED ...... ..................................................... .................... .... ..... --------------------------------------- ------------- -------DATE - ------------------.....--......--..._ . ADDITIONAL COMMENTS ----- -•--•----------•- 1 1 •• . -------...._.-- - --- ----- ... _ .--------_-----•------ --•------ ----•- -----------------------••-------- ---------- ----------•---••- -----------------------------------------...................... i -------------------• ---- ---------------•------------------._..------------•-•-...-.._...----.•-----•-•-•-•---• . Final inspection by: ._. Date ..4 . ............. ---•- Mi �3 24 1-6 v• 5MSAN JOAQUIN LOCAL HEALTH DISTRICTI� 8/?!i 3M . i