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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------- ---------------- Permit No: --------- --- (Complete in Triplicate) ---------=-- -------------------------------------------- This Permit Expires t Year From Date Issued Date Issued Application is hereby made to the San Joaqu liLocal Health District for a per to construct and 'install the work herein described. This application is made in compliance with County Ordinance No. 549 and isting Rules and Regulations: JOB ADDRESS/LOCATION .--1_.�`-" --- -- i.- - - ---_ --- - -�- -----CENSUS TRACT -------------------------- Owner's Name .. !} � ��j, l ---------------- -: ----- - -------------------"--------- Phone 1 � ,r�5 --- City - � -�j Address ---- - - - ------ - - -- l-- ---- -:-- -•---•---••- Contractor's Name .. �"'P License # Phone Installation will serve: Residence 1partment House,❑ Commercial ❑Trail�eir Court f] Motel ❑Other ---------------------------------------- ' M � h Number of living units:--- - Number of bedroomsJ..-.__Garbage Grinder//P--. L4$ize ,�G' `ice-- ---------------- Water Supply: Public System and name ---------------------------------- �- t---------------------Private Character of soil to a depth of 3 feet: Sand Silt ElClay [:3 Peat El Sandy Loam E] Clay Loam ❑ H a r d p n ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if.'public sewer is available within 200 feet,( `4 PACKAGE TREATMENT f ] SEPTIC TANK f ]:7 Size------------------------------------------------ Liquid Depth .._:-_.._.._•---------.--- Capacity --------------------'Type -------------------- Material------------- --! No. Compartments ------•--•------- Distance to nearest Well ------------------------------------Foundation ----- Prop. Line ----..---------------- 1 LEACHING LINE [ ] No. of Lines -------------t---------- Length of each sine w'"' ,__._ ... ......-_ Total Length ,._....._..,_..._._._ ..-- D' Box ____ 7ypeFilter Material .- ....__Depth Filter Material ......___................ - Ir Distance to nearest: Well ------------------------ !Foundation ---------.-------------- Property Line _-._-_._....._..--._.--- SEEPAGE PIT C 1 Depth -------------------- Diameter ----- Number ----------------- ---------- Rock Filled Yes ❑ No C Water Table Depth Rock Size ---14-"-- - ._Foundatt~Foundation '---------- Pro . Distance to nearest: Well ...................._.._.._._..---_-- -----�- p• Line ................•_--_ REPAIR/ADDITION(Prev. Sanitation Permit=# -------------------------------- ------ Date _-- -------..__..••__.._- Se tic Tank (Specify Requirements) -------- ---------__.. D posal Field (S ecify Requiremen ,' -----�--- - - /-�;-x------------------------------ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this pplication 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 in such manner as to become subject to Workman's Corn ensatio laws of California." Signed ---------------- ---- ------ - 4K------ Owner ---� ---------------------- By ------------- --------- --- ----- - - - - ------------------- t - Title - --- - - - - ��' -- - (If ot an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------------------- ----- DATE m 0'°' BUILDING PERMIT ISSUED - ----------------------------- ADDITIONAL ------------------ ------ -----------------DATE ADDITIONALCOMMENTS ---"- --------------------------------------------------------------------------------- -------------------------------------------------•-•---------------- - --------=----------------------------- ---------------- ----------------------- s------------------------------------------------------------------------ -------------------------------------- Ily ---- - ----------- -"-------------------------------- 40- Final Inspection by. 4. Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M