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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ..................... ...........•---........... {Complete in Triplicate) Permit' No. ............. ._...... --.•••••-• This Permit Expires y Year From /}ate Issued Date Issued .................. :, ...._...•._•.•..•_____________________..•.-•--__ Application is hereby made to the San Joaquin Local Health District for a per 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 ..� ........... CENSUS TRACT .......:.............::: Owner's Name ::. . ..... ........ .....---- ....---•- ....-- }., .... one ......_............................. �y �y P Address .�-. :•�!•.. .....1...4-.. ---- City '_......._ ...... .................. ....:......... . Contractor's Name -------- 1 -..�•---- - ---- - - ---License # I� Phone ..:..--•--._.._............... Installation will serve: Residence Apartment House 0 Commercial'❑Trailer Court 0 Motel ❑Other .................•-•--------..__.......-._._ l g Lot Size .AUL. Number of living ..-... _ ._. Number of bedrooms Garbage Grinder Water Supply: Public System and name ........................ ........................._.. --.... ........... ............................ Private [X�� Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat C] - Sandy Loam 0 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 side.) septicNEW INSTALLATION: (No p pit permitted if w li sewer is available within 260 feet,) � PACKAGE TREATMENT [ ] SEPTIC TANK te'] e i Siae- , .?�___ ./ ..��-r----- Liquid Depth_ .. -` Capacity . s}fJ._..._ Typ . . _.. Material__...: No. Compartments Distance to nearest: Well ....... ................Foundation ./�-•-............ Prop. Line ... .............. V) LEACHING LINE- [ No. of Lines ._.....�__..___...._ Length of each line.---- r........: Tata) Length ..--........... ••-- 'D' Box ___j..... Type Filter Material .....$J�.-•Depth Filter Material _........I��..:.........................:... Distance to nearest: Well ......540:------_.: Foundation _.-_,t-A-_•--------- Property Line .. .:.... SEEPAGE PIT ( Depth _. ..--• ----.. Diameter sZ-•--- Number ...........0............ Rock Filled.' Yes 12!r000'N o ...........Rock Size r� # ► Water Table Depth _._......... _.......:__ --� ��•• • ••�-•---- f' .•� Distance to nearest: Well ............... ....:...........Foundation ..../.- _..... Prop..Line - ----------- Distance REPAIR/ADDITION(Prev. Sanitation Permit# —........_............_____.................. Date ....--------_._................... ) , ' Septic Tank (Specify Requirements) DisposalField (Specify Requirements) ........................................-.........--------------------- .........__...................._...............I------__..... . .................................•-------------------------- ----------------......_........ (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-J iaquin Local"Health Diitrid. 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 f: as to become subject to Work Com pan satio nJaQ1yf California." Signed ... --- •------- .._... ............ Owne BY �`!` . :---. Title -- ------ :.. ... ............:....::...:..::........ (If other than owner) „ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... ::--................-................,_-........................ DATE �x_" _a. .............. } BUILDING PERMIT ISSUED --------------•--•--.....---......-----------------..._.....:•---.....----------.._....__.........--- DATE _-........................................... I ADDITIONAL COMMENTS ....................... . ................_..................... --.... ........................................................................ „ .................................... ..... ------------------ __.:..___ _ . .. __ .... __ .. .. _ .. �.0-.... _.....�___•_. Final inspection by: ; - ._ . .�.......................•---•--............----.._--•--......................---..,Date .._..r!'�"�- --.. ...._...----------••-- SAN JOAQUIN LOCAL' HEALTH DISTRICT {U�� 7/723 M