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IT OFFICE USE: APPLICATION FOR SANITATION PERMIT ........................... ...... ••. Permit No. (Cantleteln Triplicate) , --._........................ . -__........ ------------ This Permit Expires 1 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 work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIOnnN .-1--(35--1---------------- -'*� �—..__ .. .. -_` ......CENSUS TRACT . ---. l� Owner's Name _..__G[T .................... ---------------- --------------------------------------------Phone Address ..........a-uo........ ..----•�. -----------------•City ........ V------------------------------------ Contractor's Name --------------- ---- -- ..............................................................License # ......_-.;..._--------- Phone ....._.._............. ....... Installation will serve: ResidencegApartment House❑ Commercial C]Trailer Court 0 Motel ❑Other---••r--�------------------._...--.--.-------- Number.of living units:...}... __. Number of bedrooms _.�?_....Garbage Grinder _ Lot Size _V2� ............ Water Supply: Public System and name ----------------------------------------------------------—••--------------------------------------------------Private Character of soil to o depth of 3 feet: Sand 0 Sift❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam 0 Hardpan ❑ Adobe Fill Material ------------ If yes,type............................ (Plot plan, showing size of lot, location of system in relatlon to wells, buildings, etc, must be placed on reverse sIde.1 NEW INSTALLATION: (No septic tank or seepage pit perpofa2ch s seiw�err iE,s pydilable within 200 feet,} N PACKAGE TREATMENT ( ] ' SEPT[C TAN to_�-"-"---------._...__• Liquid Depth _-�.�______________ Ca aci l.. o. Ca artments ....... j I p �' 1r'� TYPe f if Distance to nea est: II _ _ __ ..Foundation -(p�-10--.- Prop. Line _ffiUA._r.�...._._ LEACHING LINE ` No. of Lines Len te__ _ r--- �b.................. Total Length ,.`�7�-------....... 'D' Box Ty e F ter aterial _ �t _ Filter Material --�-�. .........................'_....-- � Distance nearest We _-_- Foundation ( �.ar_.... Property Line.&Vel..5_......... _j SEEPAGE PIT ] Depth ________ _________ Diameter ................ Number -----....................... Rock Filled Yes E] No C Water Table ......... ........••-•-.....__!"^-7-!"-Rock Size -.--.----------------•--•------- Distance to nearest: Well .......................... Foundatldn.,................... Prop. Line ..................... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ....._---------_______._.._Le.)L Septic Tank (Specify Requirements) ...------•-•-•---•....................•-•-•--••------------•-------------------...... --- •-•---••• .. ...------------- Disposal ------- --Disposal Field (Specify Requirements) ..................••------•------ .----......._..------••-•-----•----•---------- •------.-.-_-------.--_---••---------•---------- j -- --- ' �I ------------------- -•-•---. -----------.-------- :..,..... ------------------------------------------ --•---•---------_---------... --------- ....................................... 3 e(Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin , County Ordinances, State Lcws, and Mules and Regulations of the Son Joaquin Local Health District. Horne owner or licen- sed agents signature certifiesth 'ng: 'r- "I certify that i perfa a of the ork for which this permit is issued, I shall not employ any persiftl•,in such manner as to become u st to r pensation laws of California." Signed . ....................................................-Owner-- Signed --- r .r._:, •O Title,....-__-.- By --.-_.--"-"-•-•--•------------------ --------"-•;_------_--------.._-. ------ ------------ ---------:.i (If other than ovirner]��--"""�� ( FgFjbErkRTNgNT UK ONLY• APPLICATION ACCEPTED; $Ys ----- -= --- -----------. DATE .. �.-.[."'_ .... ------ BUILDING PERMIT ISSUED -----------------. � ..............:-------DATE ........... --•--... ---------------------- r ADDITIONAL COMMENTS .-:--_-_-_--_------ ------- � ............................i -•-------- --------------..-....------------------------------------------------ ---- '!!-ti`----------- ----- ------------ `•--•------ i..............- -•-.-............................... ----------------------------------- .......-..---............. ----------•-.........-•----••----..............�_--•1........-r---i.--------.....----•-•----..._............__. -•--....... . Final Inspection by: .j-- !--------------------•----------------------------• ---------------------------------- ff ---------•-- :Date .--------_-....._-•--------- :.----------- SAN JOAQUIN,LOCAL HEAL�HDISTRICT �. E. H. 9 1-'b8 Rev. 5M _