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......... ...................... .................. APPLICATION FOR SANITATION PERMIT .....-• •l:.*..`'... ............................. (Complete in Triplicate) Permit This Permit Expires 1 Year From Date Issued Date Issued � I Application is hereby made to the San Joaquin-loc,61 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°.:... e.�;.i.. 2,...��l� • ...CENSUS TRACT ..---••--• ....--_.. Owner's Name ...... • Address .....••.-- ...Phone ...... City Contractor's Name (r. _... ..__-..License # ... ' _ ...---••---------------- Phone Installation will serve: Residence%Apartment House 0 Commercial{]Trailer Court ] - Motel ❑Other__- Number of living units,:....- Number of bedrooms ' i y Garbage Grinder of Size -T f Water Su 1 Pp Y� Public System and game � ,- / .... � ................................. . Character of soil to a de � ••-� : ..---•--•............................................... _. .� .. ::..Prl [] � depth of 3 feet: Sand Silt❑ Clay © Peat 11 San y Loom ❑ Gay loam 1 Hard an ` P ❑ Adobe�Fill Material .• ............If yes,type• (Alct Plan, showing ,size;of lot, loc ation of system in relation to wells, buildings, etc.-must be placed or reverse side NE1A►INSTALLATlON:, (No septic tank ar seepage pit permitted if public sewer is available within 200 feet .} PACKAGE TREAT �} . TREATMENT ( ) SEPTIC TANK ] Size..:. .............:_..--• ----- Liquid Depth I Capacity YPe Material....:......... - T ...---'•--•------... ........ No. Compartments Distance to nearest, Well ..................................... . Foundation _ . LEACHING LINE ( ] No. of lines "-"""" •-•••-- Prop. line _ --.....—... ._..: Legth of each line. _ Length ` .D..Box " .. Total . ....................... ..,._ ... Type Filter Material Depth Filter Material Distance to nearest: Well ,_.....r_ . ............. ... .. ; . N i SEEPAGE PIT ,C j Depth .....' Foundation ..............I......._. Property Line .................... ... --- Diameter ................ Number .. Rock Filled Water Table Depth Yea N oCIE ------•. ....------ . .......Rock Size _ Distance to nearest: Well FPAiiR ADDITION.Pre .......... ............................Foe ndation Prop. Line ' ( v. Sanitation Perrnit _ ....... ................._ r •----.... Date Septic Tank (Specify Requirements} , ► :. Disposal Field (Specify Requirements) ��p• k e[ ..c Xy+_'.:.1��•�....... . .... .. . .... 514 ............................... ......._ .� .... ................................... ---•---•-- --• ••---•.............. •. f - raw existing and required addition on reverse side) . I hereby certify that ! have prepared this application and that the work will be done In accordance wi County Ordinances, State Laws, and;Rules and itegulatlons of the San Joaquin local Health Districtth San Joaquin . Home owner or liven- sed agents signature certifies the following:` "I-certify that in the Performa ce of'the work for which this as to become subject to W an's Gampensati laws o Cpermit Is issued, I shall not employ any person in such manner I t" Signed �_----••�------• • . ,.-,. Byw�` . ..._........ -r4;4 ............ ...... ... /� (If other than owned % ••-----•••-----•••_- FOR EP MENT. SE ONLY APPLICATION ACCEPTED BY__.:. BUILDING PERMIT ISSUED .--- '-......_ -- _ -, -- - - -•---- DATE ,..��.................. ADDITIONAL _. COMMENTS DATE ...........................:..................... ................. .•--•--......----........._...._...................1........ ........... 'I Inspec#ion by: ...... ................................................. ............. ` :�= G` l✓. J.................................................Date7�}....... SAN JOAQUIN LOCAL HEALTH DISTRICT