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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 1Complete in Triplicate! Permit No. ................•___- _............................•........................... This Permit Expires 1 Year From Dot*Issued Date Issued - --y.- ...... Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install tate work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..-. I .....�-c f Z i✓ - .................... .....CENSUS TRACY' ....I..................... Owner's Name r'- �= v �. ................ Phone . Address /.i:C..-.... Contractor's Name r� -�, ....License Phone -•----• ........ -................... � ... Installation will serve: Residence ❑Apartment Housefl Commercial❑Trailer Court 0 Motel ❑Other....................•••- ................ Number of living units:..- --- Number of bedrooms . ;`Garbage Grinder ............ Lot Size ............................................ Water Supply: Public System and name ................. ...... .... -.............Private] Character of soil to a depth of 3 feet: Sand❑ Silt Q Clay ❑ Peat❑ Sandy Loam ❑ 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, NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT I ] SEPTIC TANK I ] Size................................................ Liquid Depth ......................... Capacity ------------•------- Type -•--•---•----------- Mater' I..................... e. Compartments ...................... Distance to nearest: Well -•---------------- ...... --------Foundation . ............... Prop. Line .....-............. . LEACHING LINE [ ] No. of Lines ------------------------ Length of oft line----......--- ... Total Length ........................... - 'D' Box ............ Type Filter Material ....................Dept Filter Material ............................................ Distance to nearest: Well ------------ ----------- Foundatio .................. Property Line ........................ SEEPAGE PIT [ ] Depth ------------- -- Diameter .......... Numb r ----.....- ------ Rock Filled Yes ❑ No 0 Water Table Depth — .[tock Size Distance to nearest: We -----•....................... ..........f=oundation ----.- ":.......... Prop. Line ........-----.--...... REPAIR/ADDITION(Prev. Sanitation Permit# ---•........................................ Date .._..... ...................... Septic Tank ]Specify Requirements) t'------• Y.. Disposal F' Idy(Specify, Re irements) �-.. g... ....... 1 -- -- ----- ----- ------ ---.- {Draw existing an 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 lice"- 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 yorkM 's Compensation laws of California."Signed ---.. .... --• -------- Owner BY 2----------- ----------•-- — -------•----------- -..- -••---- Title - •- ----------- (if other than owner) FO DI:PA ENT USE ONLY ' APPLICATION ACCEPTED BY __ DATE�___ •. _.....,_.__..-. - c3-7 ------------------------------•_••----- ---------- •-- --- .............. BUILDING PERMIT ISSUED ...'----------------------------------------------------•-• - -------------------- - .----------- .---------DATE . ------------------------------- ADDITIONAL COMMENTS ---- --•--• -- - i Final Inspection by: -•-----•---•.............. ------.. . ....•--•--------- -- ...- -----................•.........................Date ----�-`3`_�-�...-........-. Ell 13 21a J-�8 lay. I � ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M �' I