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FOR OFFICE USE-. APPLICATION FOR SANITATION PERMIT - Permit No. . ...�.1. (Complete In Triplicate) ,t .• - �.. .Date Issued 3- ..................................... ( This Permit Expires I Year From Date Issued Application is hereby made to the (Son Joaquin Local Health District" for a permit to construct and Install the work herein described. This application is made in compliante with County Ordinance No. 344 and existing Rules and Regulations: JdiADDRESS/LOCATION .. ...:.......... __.. ... .. . ........ff. .........•......._ - :..... ......................CENSUS TRACT .......................... Owner's Name _..� ...... s�rz..................... ............... ....................................Phone ......... .......................... Address . . . ....... ....J�. -m�.. _.....•...... .. ..... ._..... _ City ...................... ...............................................��%��/ 7 •Contractor's Name .._.... ` ... C License #t,�.f �a. .... Phone . . installation will serve: Residence❑Apartment House❑ Commercial ❑Trailer Court MotelQ Other ..............................._... ........ ti Number of living units:.4 -- Number of bedrooms ............Garbage Grinder ............ Lot Size ... -•� � Water Supply: Public System and name ............................................................................................. Prlvate,� 1 Character of soil to a depth of 3 feet: Sand D Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam] Hardpan Q 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 side.) I NEW INSTALLATION: `INo septic tank or seepage pit Itted if public sewer is available within 20t) fest,} PACKAGE TRI ATMENT ( ] SEPTIC TANK. Size................................................. Liquid Depth .......................... Capa`citY t---•--------------- Type ---.------------.... Material...................... No. Compartments ...................... Distance to nearest: Well .......................Foundation ....................... Prop. Line ...................... LEACHING LINE ( ] No. of Lines ----- ---------------- Length of each line.-...�.(�....... ..____ Total Length �.��..- U 'D' Box ....... Type Filter Material ----------..........Depth Filter Material ........ ............................. W Distance to nearest: Well ..................----- Foundation ......................... Property Line ..... .................. Rack Filled Yes No SEEPAGE PIT ( } Depth L . ..��.X./_" piameter ................ Number Water Table Depth ---------------_-- ................Rock Size .......................... Distance to nearest: Well ........................................Foundation ..................... Prop. line ...................... REPAIR/ADDITION{Prov. Sanitatioii•'Permit ........-.....----------•-------• - Date .....__a....................__..} ! _ .........................................................._..... Disposal Field (Specify Requirements) - -,--�•- - --=---------•--- -----------•----- . ._.......__..... --- ............ ...................................................... --......•• .......:........__..........._....... .r •-----..... .. --------------- ----------- --------- ....................................... ....................................................._..... op n i lDrow 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 Laws, and Rules and Regulations of the San Joaquin Local Health.District. Norte owner or licen- sed agents signature certifies the following: r "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 Workman's Compensation laws of California." Signed .... . ........ r Owner &�� ........... Ir ------• •----•-•--- Title .................. .......... ....... :... _...-..... ...._.......... ... BY - _.... �` (if of tho owner} - FOR DEPARTMENT USE ONLY e DATE .5 .APPLICATION ACCEPTED BY . -- ... ................... .� h , .: DATE ...... ................... •- _. ....... ............................PERMIT ISSUED .--_-'.' ---...... -•----.._ - ADDITIONALCOMMENTS .. ..__ J.. ......... ...................... ....................._..-............._.......... . ................................................ ................................. I---•------ ------ ............ ..................... ....................................................................................... -------------------- .._.......--------.............................. .--------------------------.._.-------_-.._._.--.-.-... ---- ..I.......... . •----_.. Final Inspection b ��e .... . ..... ... ........ .... EH 13 24 1-68 Rev 5'M SAN JOAQUIN L CAL HEALTH DISTRICT 8/7$ 3M CO