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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ................................... -----••----•-- (Complete in Triplicate) .......... ... .•..__...,-.._.---...__.._ .........�.... Date Issued �_.........--•--.. ....... .... . ........... This Permit Expires ] Year From 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. 544 and existing Rules and Regulations: i'ttJ ISL.................................... JOB ADDRESS/L AT N ,. CENSUS TRACT _ .�. .Phone Owner's Name ra.-••. - •-• r ................................:. Address City j? . . ._... 3 . . . ' - Contractor's Name -•-_• •- - -License # /-+��• -� Phone .. { Installation will serve: Residence partment House i❑ Commercial❑Trailer Court 0 .i� i Motel ❑Other --•--..•.....-..............:... Number 7liv ng units:............ Number of bedrooms .... ____...Garbage Grinder ............ Lot Size __-_d� -•-- ---- ".._.....PrivateWater Supply: Public System and name --- ..---.-------•••-..... ..........----••--._..__-.-•--------•------Character of soil to a depth of 3 feet: Sand❑ Silt[ICiay ❑ Peat C] Sandy Loamy Loam ❑ ,� Hardpan ❑ Adobe ❑ Fill Material :......_.... If yes,type ..--_--- ----- LA5 (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,) Size:•------------ --------•--••------•--•-- Liquid Depth ......................... SEPTIC TANK. . . i PACKAGE TREATMENT j I , Capacity .................... Type •---------•-•--- Material.................. - No. Compartments ...................... Distance to nearest: Well "`•Foundation ...................... Prop. Line . •------ ....... ii LEACHING LINE [ ] No. of Lines_.........=_-- '= Length of each line---------------------------_ Total Length ... ........................ 'D' Box ....... Type-Filter Material ............ Depth Filter Material __..--........................•--.._....__._ Distance to�nearest:-Well..............::.......• Foundation .. .................. Property Line ..............-----..._, t l 1 � ___ Rock Filled Yes No ❑ SEEPAGE PIT ( ] Depthy Diameter •-----__- ---. Number ....................••--- ❑ Water Table tepth�. __Rock Size --__-_-•_...----•........-••--.. _ P_,. Prop. Line Foundation ............•........ . Distance to nea-rest• Well ................... _._......._._.....- -------------- --------•_... Date .................................. REPAIR/ADDITION(Prev. Sanitation permit# ----••--•---••-- • ...._....... _ ._..---.._-• --•------••--• Septic Tank (Specify Requirements) ..................... - - - ............ -__- Disposal Field (Specify Requirements) .- ��-••• --- I ................... -------•----- .............. ---------•- IDraw existing and required addition on reverse si e I hereby certify that 1 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 Rcan- sed ag . entssi.gnature certifies the following; __ --.. . arson in such manner "1 certify that in the performance of the work for which this per is issued, 1 shall not employ any p as to became subject to Workman's . pensation laws of„California” . x Signed ...................••---------••---- _. o- wner - Title �. .._Q'�- - •--•- (If other than owner) i FOR.159PARTMENT USE ONLY -ry .......•--_.. ..--•••-•-_., DATE . •- ................ APPLICATION ACCEPTED 13Y .:.�. .s : - ...._.__ DATE ------------ .............................. BUILDING PERMIT ISSUED .............---------.........>......................................:. ....... ......... . ......:.__._.... .. ADDITIONAL COMMENTS ._....._----------•................................ ..............••----. ---••••--........................... .-- -' - ... .. _......----.... - ...:. .-1...-n...�1_1�.....----.:-...._'! .._ ........ ,�r.:.. :....... . ----•.......... . --------- ...•.. to •••....._z......_ Final Inspection by: ---•..----•---`••--•• •spa •%f � � ' SAN JOAQUIN -LOCAL HEALTH DISTRICT 7/72311 r u 13 '24 1_'AA Rnv- SM