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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete In Triplicate) Permit Na. ..................... d .ue � ... • This Permit Expires I Your from Date issued Date iss ....------•_...... Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein described. This application4 m de In I a e with County Ordinance No. 5' 9 and existing Rules and Regulations J� S , JOB ADDRESS/LOCATION ..... ..F1 .��- _-�. -P��.--- ...... / �? -CENSUS TRACT' ........................ . Owner's Name ....l7'� ` �� 7Z`�/C� ��" .Phone Address ScS� - City _.. d...9 --•-••....................... --- .._....o� = i_......__._. r� Contractor's Name ....................... -! ..__ .. �''� License # $ ... Phone -r,'17-: Installation will serve: Residence 0 Apartment Houseo Commercial oTraller Court � Motel {]Other--- IT;I;—:,_. Number of living units:............ Number of bedrooms .4;.?.....Garbage Grinder ............ Lot Size Water Supply: Public System and name .......-..........................................•-----. ....... Private Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay p Peat❑ Sandy Loam C) 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.) T NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT REATMENT [ ] SEPTIC TANK f I Size--- � .......................... Liquid Depth .......................... 1" Capacity ............... Type .f.....paa_41Material..._.._....------ _ No. Compartments Distance to nearest: Well' .......... Foundation ... ... Prop. Line ...�f Jl LEACHING LINE { ] No. of lines ...... .. Length of each line...... 42.......... Total Length�_. a ............... 0 'D' Box . Com-Type Filter Material J_t..........Depth Filter Material ..._ .............................. I �N e� Distance tonearest. Well .... .........�FoundaHon ....../...C�.'1�...... Property Line ...$_.:'........... Depth ... ............... Diameter q_.Y g. Number .._. .................. Rock FII d Yes No ip Water Table Depth ............... .Rock Size Distance to nearest: Well .... �... ----t�dQ._...---•------•---....Foundation ...jr;�_--at...__ Prop. Line .....c�..�..' REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. Septic Tank (Specify Requirements) {° Disposal Field (Specify Requirements) ....................... ----------------------------------......................................... --------------....................-..................................................................................................................-.__............................................. ..---•................................... ------------.............---- ............._..................................... -•-------•-...__........ ............................. . (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 Joaquin Local Health District. Home owner or [icon• Sed agents signature certifies the following: "I certify that in the perfor nce of the work for which this permit is Issued, I shall not employ any person in such manner as to bWbcfr an' mpensation s of California." Signed . ...- Owner... . . ••-•--By ..---•- = .. ... ---- --- -- -----•----•••----- --.. xitle .....�. F..---...........__owner) FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY ......................-•--.._......-----....._............-•--•-........_._........._...----•- --.. DATE ........ ................................. BUILDINGPERMIT ISSUED ........................................................ .................................................DATE --....... ...............------............. ADDITIONAL COMMENTS ------------ ---------------------------- ------------•.......... ....... ------ .__. _,..... .. ._......._...._._..,,.._....__._.................... ......................I.............. Final Inspection by: ._..... .............. ......Date -•----......... ESC 13 24 1_6 ve SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7{I 3M