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FOR OFFICE USE: -- APPLICATION FOR SANITATION PERMIT - - (Complete in Triplicate) Permit No. This Permit Expires T Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the A described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regu ,ff,2--s /JOB ADDRESS/LOCATI 40- � + --- . --_-_CENSUS TRACT .___-___- Owner's -Name _______________ -- ------ - Phone oneAddressX --- � -----Contractor's Name _.-___ � I City -----4 - -------. License # Phone ----------------- Installation will serve: Residenc APartment House❑ ommercial railVCourt�Q Motel [_1 Other --- ------- --------_--- ----- ---- - Number of living units:__.. Number of bedrooms ---1.......Garbage Grinder .. ------ -. Lot Size _..-Q ---trc Water Supply: Public System and name - ----------- _ -_ "_- - - ------------------ ----- ---------------------------------------------------Private (!T Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Q Peat ❑ Sandy Loam Q Clay Loam ❑ 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 sig NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size- • / � ' 11 --i X---7--- X-`-r-- - "-- -- Liquid Depth __q-_-------------- Capacity 1-3-VO-C, _-,- Type d Material_0OW---__- No. Compartments Distance to near st: Well . _ `�O ----__Foundation ----LO___-------- Prop. Line --- No. of Lines LEACHING LINE N [ 5--41 `--- Length of each line -e)�----------- Total Length .-Z P-q------ ........ 'D' Box --_ ------- Type Filter Material .___-S�_��------Depth Filter Material F- Distance to nearest: Well ----------- Foundation Foundation -_fes__._.-_..--_-__ Property Line SEEPAGE PIT [k Depth ___ _ -� Diameter c-;_3_��_- Number ---____.-7_✓______ _________ Rock Filled Yes No iQ Water Table Depth --- ----------Iva- ---------------------Rock Size ---I 1-0C ------ ------ Distance to nearest: Well ___-----f_0Q..____._.___-._._...Foundation ----- C� Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# __- ___ _._-_---------------------------- Date ._____-_-____•_-_•_______________) Septic Tank (Specify Requirements) ------- -------- ------ ------------------------------------ -"------------------ Disposal Field (Specify Requirements) _________________________________ - - - ------- -----------------•-------------------------------------------------------- ------------------------ ------------------------------ ---- ------- -- .. - (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 licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workm 'I Compensation laws of California." Signed -..- -- ------------- ---- -- -- C! ---- - - BY - - --- --- - --- ------- �= Title _- (fz� - X l - ------------------------------- (If other than owner) FOR DEPAR ENT USE ONLY APPLICATION ACCEPTED BY._t, 4 ----------------------------------------------------------------. DATE -----------•--------- BUILDINGPERMIT ISSUED ------------------------------- ---------------------------------------------------------- --------------DATE ADDITIONAL COMMENTS ----- :'>` •1 -•------------------------------------------------------------------------------ .. <._ --------------------------------------------------------------------------------------------------- -------------------- - - _ -------------------------------------•--------•-----------------_-------------------------•----•---------------- ..-__._ _________________________-----______�__ __ .__- _ ____-__---__-_____•-•-__---_-__-__-______-__•-_____-_-_-_•______-_-_-__-_-.---__ jl _ ___.___.. _ I Final Inspection by: - _-� :. -------------------• ------------------------------------Date - -- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT