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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicpfe) I ` Permit No. ........... ,.-....... .................................... i - ---------------- This Permit Expires 1 Year From Date Issued Date issued ......'............ 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: JOB ADDRESS/LOCATION Owner's Name ..... ..................CENSUS TRACT ......---•................ .... .. ..r-..-1.--- .�� ..................................................... ......•--------------........Phone ............... Address .. ... ---•-- --------- City Contractor's Name .. . ....---- - - •----- --- License # .. Phone . Installation will serve: Residence JdApartment House Commercial ❑Trailer Court C] Motel ❑Other .. . .... ............. 1 Number of living units:.. _'_.. . Number of bedrooms .5-------Garbage Grinder ------ Lot Size ...`��. .Q'�! 'Q- .............. Water Supply. Public System and name - -.- -- ------ ------- --------------------------------- ------------------•----..Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ . Clay ❑ Feat❑ Sandy Loom ❑ Clay loam ❑ Hardpan ❑ Adobe X Fill Material ............ If yes, type ._ IPlot 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 t ] Size----,------------------- ................. .. . Liquid Depth .......................... Capacity - Type(t �. ...._ Material ?�'�^; -?_.. No. Compartments . ..............J Distance to nearest: Well . ..- ....Foundation Prop. Line ....LOG�. ... LEACHING LINE [ ] No. of Lines Length of each line .. 90� ..._... .... Total length .....k49 Line's /I 'D' Box .... Type Filter Material ..De th Filter Materialvrg Distance to nearest: Well ..�.?ra..........--.- Foundation 1. --------- Property line :� ............... SEEPAGE PIT [ ] Depth �d� �.-----... Diameter 4X.8?)!?-. Number _..A- Rock Filled Yes &""' No C 1 Water Table Depth ............. .... .. . Rock Size .. ......- Distance to nearest: Well _H.................................•Foundation ........ -.-...-- Prop. Line ---------------------- 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 licen- 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;insuc/hhmnnw as to become subject to Workman's Compensation laws of California." Signede�. . .'._ ,... '.... -----------------------------------------._ Owner By --------- ..........-.......................- .......... ..... Title ........ ... ... ........... ............... . (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . ............ _ . DATE ... �1-7,'-5... ........... . BUILDING PERMIT ISSUED -... ..... .......... . ... ................... .. .. .. ... ...DATE . --._. ADDITIONAL COMMENTS ................. ....................................... --- ------------------- --------------- -------------- ------------ Final Inspection by: ---------- -------•----- --- ............... Date .� � ....-............... SAN JOAQUIN LOCAL HEALTH DISTRICT 6 _ ,13 243 5M.