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i d FOR OFFICE USE: u" APPLICATION F& SANITATION PERMIT ------------------------------------ 7 �`f (Complete in Triplicate) Permit ......... .............................................. This Permit Expires 1 Year From Gate Issued Date Issued ...�'.:�q: s` 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: JOS ADDRESS/LOCATION � ..........CENSUS TRACT ..............:.......... : t Owner's Name ...............c�. _/ �.................................................... Phone _....._....... ..................... Address 5Z1c7� r� Contractor's Name ...._. �ll"t -------------------------------------------------------License # Phone ... Installation will serve: Residence ❑Apartment House 0 Commercial❑Trailer Court ;❑ Motel ther 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❑ Clay ❑ Peat❑ Sandy Loam lay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ............ If yes, type --..------.---..-.--.------- " I (Plot plan, showing size of lot, location of,system in relation to wells, buildings, etc. must be placed on reverse side.) W 1 NEW INSTALLATION: (No septic tank or, seepa a pit permitted if public sewer is available within 200 feet,) "\A PACKAGE TREATMENT ] SEPTIC TANK 1 Size...................................�.• ---...._.. Liquid Depth ........................... Type�p - . ... MatericiI4 No. Compartments Capacity /! ............ istance to nearest: Well -__14'20'Y`_..................Foundation --------- Prop. Line ....T `............ ' LEACHING LINE j No. of Lines .J.................... Length of each line---..... --------- Total Length --- .......•--.._..--•.---. 'D' Boxr1._ .__._.- Type Filter Material ....•---... Depth Filter Material ----- .............................. Distance to nearest: Well G?d..y....... Foundation ...._. .! Property Line • . SEEPAGE PIT l.........� Diameter a''..�...... Number ........ .._.�.... ...... ...... Rock Filled Yes a No ❑ J ; Water Table Depth .........................................4.......Rock Distance to nearest: Well .._._ ._? .....................Foundation ....15 ........ Prop. Line REPAIR/ADDITION(Prey. Sanitation Permit%# ............................................ Date .................................. Septic Tank {Specify Requirements) ....._ ............ --------------------•--..--_.__..------ ............:......................... _.---------....... DisposalField (Specify Requirements) -------------------------------•------------------------------...------------ ----=--............------•-------•---....-------------- .............................. .....................................----------------------- ...... ---- ...... (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 Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: I "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Wo man's Compensation laws of California." I , Signed ................ ........... ....... Owner I BY •..................................•--.............:......._....-•---•=-----------------•---•--........ Title ......................................................................... . (If other than owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ............:. . ..................................... DATE r...--��f-----------.... BUILDING PERMIT ISSUED --------------•-----._.....-----------------------•-•-------••- DATE ..... ADDITIONAL COMMENTS ..A------- -------------........................................I......... .............. ..................................................................................................•-•..........._.............----•••---•-•-------------------•----------- ...................................••---------•-•---•------ ........................... ................................... •----------------------------------------------- -- ------------.---------------........_....-•----------. _......... ._...... Final Inspection b — _Date .................... „SAN..,JOAQU.IN LOCAL HEALTH DISTRICT a ” 1_-1 214 , :ten n___ e,■ 7 I77 u