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FOR; OFFICE USE., �� . .,APPLICATION FOR SANITATION PERMIT ... ... ......... . Permit y (Complete In Triplicate) ........................................._.............. ......................................................... 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 appli ati is made in compliance with County Ordinance No. 549 and existing Rules and Regulationst 4JOB ADDRESS/ C� TIO ........ . ....".! !. CENSUS TRACT ......... ................ Owner's Name _..... ...... r ,................................................:................Phone . .7.7` c ...... Address. . _ .... .. �� 3 .......... City ..... .... .......... .. .............. 1 �L� Z - r Contractor's Name .............. ............. •-S -}/` ..............License ils�.�. 333..... Phone .. ....... � 7. Installation will serve: Residence KApartment douse 0 Commercial❑Trailer Court ❑ Motel ❑Other ............................................ Number of living uniti._...... Number of bedrooms Garbe a Grinder Lot Size .�� Water Supply: Public System and name ...................... .......................................................................................Private Character of soil to a depth of 3 feet: Sand❑ Silt[3 Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑. �: Hardpan❑ AdobeA 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 ( ] SEPTIC TANK Size......��'..�1X�.�•-.- ........ Liquid. Depth .. .�............. .- Capacity Type .. ��•-_- Material...� -zrt-G- No. Compartments ...................... � r . Ci Distance to nearest: Well .............�?..Q_...............Foundation ....t -........... Prop. Line .n?........:........ LEACHING LINE 1P No. of Lines .......Z.—....... Length of-Poch line.-6v. s t.z.'... Total Length l*................... � 'D' Box ......�Type Filter Material . ..._.....Depth .Filter Materia} ......(.�.��........................... Distance to nearest, Well ..... b..�......�_. Foundation .._...Z.0........... Property Line .. .................� SEEPAGE PIT Depth .Y..0_ r......._. Di{ameter"Y-4+�'(.O.&Number .........2—' ....... Rock Filled Yes � No ❑ o ��1t7Jc�ca Water Tabic Depth Rock Size ....{? t..._._._..foundation .....!Q..::}.._. Prop. Line ...�.. f' Distance to nearest: Well ............................ ......... 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 far which this permit is Issued, 1 shall not employ any person in such mane► as to become subject to Workman's Compensation laws of California." Signed ----------- --lotihet -`------ Own er -A- BY --------------- -- __ --------------*- _._ - Title ------.--.._... ................ ---------- iii owner) R D PARTMENT USE ONLY APPLICATION ACCEPTED BY --•-- - - -------- " DATE .......I/. T� .7.�................ BUILDING PERMIT ISSUED --••---- :... :..-..._..DATE .......................... ADDITIONAL COMMENTS --------------------------•----- - -- ---------------•.....------....----------.--•: --•---•---•-•--.:..... -------------••--•------------------ ._.............__....---.....---..._...._..---- ------....._..._. .................... Final Ins Section 6 ........................................................__.........__......... ..._.._..._._.....-_�` . F Y' •- •---•------ a ...... - • •-- - •----•- -----•-----�--------•---•--------------• - ---- --._..._.........-D to ......-- ...-�_. .............,......_... EH 13 2a (-fila v 5I SAN JOAQUIN LOCAL HEALTH DISTRICT 6/7h 3M