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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ............................................... (Complut* In Triplicate) ................................. ......... ....... Date issued 10/0.12.9 ...................... . This Permit Expires I Year From Data Issued Application is hereby made to the San Joaquin Local Health District 'or 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: ......CENSUS TRACT- ...... ......... . JOB ADDRESS/LOCA 7T N ....1K Phone..... . ...... ... ...... OM6 .. .... .. ...... .............. ....... Owner's N 'L....... ity.... Address.... ...... . . C .... License # one. . ..... Contraear's Name.. ... 4"n— installation will serve: Residence Apartment HouseCommercial D Trailer Court El Motel E] 0 t her ....... .. Number of living units:..............-Number of bedrooms.__.., ...Garbage Grindw............Lot Size.. ...... Private Water Supply:.Public System and name................ .... ....... ...... ... Character of soil to a depth of 3 feet: Sand [] Silt❑ Cl'ay-�/Peo.-E)--So,ndy Loam ❑ Clay Loam El Hardpan 0 Adobe F-1 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 I I SEPTIC TANK I Size. . .............. ..... . ...................Liquid Depth . . ..................... Capacity. . .. ... ........Type.... .. ....... Type.... ....... Moterial.. ............... .. ..No. Compartments ........................ Distance to nearest: Well Foundation.... ............ ........ Prop. Line............................ Length of ecch line .............................Total Length .... ..................... ............ LEACHING LINE No. of Lines........... 'D' Box . ... ....Type Filter Material Derth Filter Material............. . ................ Property Line ................. Distance,to nearest: Well.. Foundation ......... Rock Filled Yes E] No ...Number............. . ...... SEEPAGE PIT Depth Diameter ❑ .—Rock Size ......... Water Tabie Depth ..... . . ............. .............. . p. Distance to nearest: Well ...........................Foundation ....... ...... ProLine....... . REPAIR/ADDITION (Prev. Sanitation Permit#.... ..... .. ......... .....................Date . ........ ... .. ..... .......... Septic Tank (Specify Requirements)..... . .... ..*........ Disposal Field (Specify Requireme.,ts).... .. ..... -,X ...... .......... ................................... ................................... .................. ............ ..................................... .................. ...... . .... ........ ... ........................ .. .. . .. .............. . . . ....... ........ ... ........ .............. (Draw existing and required addition on reverse Side) I herelay certify that Ihav e prepared this application and that the work will be done in accordance with Son Joaquin County Ordinances, Stat,�? Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: I certify that In the performance of the work for which this permit Is Issued, I sl. A not employ any perfon in such manner as to become subject to Workman's Compensation laws of California." Own .............. h 2/51 Signed it Xe-,-e-14sl I By.. .......... . . . (if other than owner) 7 Al FO DEPA MENTUSE ONLY ?DA7TE APPLICATION ACCEPTED BY DIVISION OF LAND NUMBER DATE. ADDITIONAL COMMENTS ........ ....... . ..... . .. ........ ..... . ....M... .... . .. ...... ...... ............ ... ......- r .. 113 .... ......................... ...... . ate . ...... . ........ D Final Inspection by: F&S 21677 REV.7/76 3M EM 13 24 SAN JO0N LOCAL HEALTH DISTRICT