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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit ............................................ {Complete in Triplicate) ............... ...........•...................................•---__-.._ This PermltExp#res 1 Year from Date Issued Date issued ............ .� Application is hereby made to the San Joaquin Local Health District for a permit to construct and Instal) the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOCATION ..._ .9._.. ...�- ?l�.F/i� TT ......-- •----.......MSUS TRACT .......................... Owner's Name .-......4a7X)•--. ..........................................................Phone ...... 37- . 012-3 G2.../V_.__.....�'' iPaS/�1/1� v. ......-------.... Address ----- City .................................... Contractor's Name .. � S—l ' v". / IYP�_....�,�...-----.Lloense��.��.. Phone Installation will serve: Residence VApartment House f] Commercial OTroller Court IJ Motel ❑Other......-..............-...................... Number of living units:.../------- Number of bedrooms ----!......Garbage Grinder ............ Lot Size ............................................ Water Supply: Public System and name ........................................................_-.......--..........................................Private Q. Character of soil to a depth of 3 feet: Sand n Silt 0 Clay ❑ Peat❑ Sandy Loam 0 Clay loam ❑ Hardpan p Adobe 2) 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 [ SEPTIC TANK f } Size................................................ Liquid Depth .......................... '] Capacity --•--••------------- Type ---- ............... Material...................... No. Compartments ...........-....... Distance.to nearest: Well ....................................Foundation ._...._ .............. Prop. line ...................... LEACHING LINE [ ] No. of Lines -------------•........_- Length of each line............................. Total Length ----•.................. .---- 'D' Box ............ Type .Filter Material ....................Depth Filter Material ............................................ " Distance to nearest: Well ........................ Foundation ........................ Property Line .................... ... SEEPAGE PIT Depth ----- ----------- --- Diameter ................ Number ---------------------------- Rock Filled Yes n No [ ) - Water Table Depth ........................................Rock Size -............................... Distance to nearest: Well .Foundation _ Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------- ------ Date _..........__._.__. ............ Septic Tank (Specify Requirements) ...:.......... ..................... ....................................._..........................I...... ...._ - ..._...... Disposal Field (Specify Requirements) - .-------- /`r` -- _.t.Q_ rtf04 _ (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 Joaquln County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heal&District. Homs owner or liven, 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 s Co sation laws of California." Signed ------------- --------------------- -•------- - - - •---- --••--•--..... .............. Owner BY '-...- --------------•-•-- ...._ Title ..6. YY1�'4.d7T -----••----- -------------------- (If other th wner) R D PARTMENT USE ONLY ` APPLICATION ACCEPTED BY ------ --- -- DATE ....- - ..-_.....--••- BUILDING PERMIT ISSUED --------- -- =- --- -- - f = � ...................•---------.._....-_..__.._.-----....._.._.__._._._....._DATE - -----------•------........-----.....---- ADDITIONAL COMMENTS ------- -- ------ ---- ------- ------------- -------------- ------------ - - ---- ------- -------- ------ .................................... fiFinalIns ion b ---------------•---..-----••----------------------••---------•----------------------- ..... ..- .__..._..-------....-EH 13 24 1-68 nal Inspection by: ..._._ . - f ----••-------------- ------ -------------------------------------Date – ..---- SAN OAQUIN LOCAL HEALTH DISTRICT 8/7li 3M