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FOR OFFICE USE: t APPLICATION FOR SANITATION PERMIT Permit No. JCornplete In Triplicate) ................. a- ....................... .............. ... ............ .. ........ This Permit Expires 1 Year From Dow Issued Date Issued J�...7. ... ....... Application is hereby made to the San Joaquin Local Health District for a permit to construct anc install the work herein described. This application Is de In compliance with C unty Ordinance No�49ond existing li ules and Regulations JOB ADDRESS/LOCA i-•... D34JJZ1� ......... ........ ........CENSU TRACT .......................... . �f Owner's Name F_ t... • --------------------•--•--- ----------- Pho a -� 1` ., Addres . . . •. City . Contractor's Name -------------------------------License # ---------------------- hone ......--•-••.................. Installation will serve: Residence[]Apartment House C) Commercial OTroller Court ❑ Motel [}Other ..................................... Number of living units------------- Number of bedrooms ._...Garbage Grinder .........-.. Lot Size _ --------------------------------------- Water Supply: Public System and name ..-•------ ................................----..........--------------------------------------L.............Private❑ Character of sail too depth of 3 feet: Sand❑ Silt❑ Clay eat❑ 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 sidell. NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK I Size--------------------------•..................... Liqut I Depth ....................... Capacity 0-- -...... Type . _--- Material...................... No. m artments -----Zr._. Distance to nearest: Well Foundation.+I8_ _ ___o_... Prop. Line LEACHING LINE [ ] No. of Lines -- ---------------- Length of each fine............................ Total Length - .. D' Box ._..__.._... Type Filter Material ....................Depth filter Material ... ...__.. ................................ Distance to nearest: Well ........................ Foundation ------- ................ Prop sty Line ........................ SEEPAGE PIT [ ] Depth Diameter ................ Number ............................ Rock Filled Yes ❑ No DC7 Water Table Depth ----------------- --------- ....................Rock Size ------------------------ ------ Distance to nearest: Well ........................................Foundation -------------------- Prop. Line ...----............... REPAIR/ADDITION(Prov. Sanitation Permit# ---•---------------------------------------- Date ---.......................... Septic Tank (Specify Requirements) ................. y................... ........... . ...._ r ....... r ~ Disposal Field (Specify Requirements) a. . ....,.l ....... .. .. ..... , --------------------- - •- - �.a_ ...... ---------------- -----------------------_------- ------ ------------------- I raw existing and required addition on reverse side) 1 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. Homo owner or licen- sed agents signature certifies the following: "I certify that in th erformance of the work for which this permit Is issued, I shall not employ any person In such manner as to became to Wor Cam ati Taws of California." Signed ....--- - - -- ------------ ................ Owner By ---•------------------------------------------------------------------- ---------------- ------------ Title ............................... (If other than owner) F01 DEPARTMENT ONLY ' APPLICATION ACCEPTED BY --------- --------- ---------------- DATE �p '' - . BUILDING PERMIT ISSUED .. •--------- ------------------- DAT ADDITIONAL COMMENTS ---------------------------------- -------------------- --•----- ---------- ....-------------------- --------•gRev. -------•- --- --- ------ - ------------ ----------------.......................... -__.. ._ __________________ --___-__-.-. .____..___.__ __._ _ • _____ ____ __ ______________________________ _ E� Final Inspection by; .. - - - - --------- -- -•- ---• --••--Date . .. C� EH �3 2� 1—Cali � f ��_..__ SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7]t 3M