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.: ..... APPLICATION FOR, SANITATION PERMIT Ai 7S `�� (Complete In Triplicate) �• Permit No. ........ ..---•......................... , This Permit Expires 1 Year From Dab lstued} Date issued - - Application is hereby made to the San-Joaquin Local Health ©isfirict for a permit—tooC nstruct and- install-the work herein described, This application is made in compli nce with County Ordinance No. 549 and existing Rules and Regulationst i JOB A.DDRESSAOCATION .......-. �.. ¢ .... ... ... .. .. CENSUS TRACT Owner's Name ..... " Phone Address ................ ._ City -- ' ............... Contractor's Name ----- -----------.License #�_��Tl. Phone _. � 2 �_� Installation will serve: Residence❑Apartment House j] Commercial❑Trailer Court Motel.❑Other ------------- Number of living units_____________ Number of bedrooms __.._ ...garbage Grinder ------------ Lot Size Water Supply: Public System and name .__.._.._.. -------------------------------------Private ❑ Character of soil to a dep#h of 3 feet: Sand Silt❑ Clay Peat-Q,,,..Sandy Loam-�fay Loam Hardpan ❑ Adobe Fill Material ............ If yes,type ............... ............ (Plot plant, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse sldo , NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANIC ___...._._.. Liquid Depth ............... l Size------------------------------••--- - __...--- - Capacity ------------------ Type_.... ------ Material- ----•............ No! Co artmen#s _.........._.. -_ i -1 -- Distance to 'nearest: Well ----------------------- - ----•-----Foundation -----•-----------_---_ Prop. Line .................... LEACH114G LINE [ j No. of Lines -------- Length of each line............................ Total Length 'D' Box _._......... Type Filter Material .__...__----..----.Depth Filter Material . ............I...........? Distance to nearest: Well _.."""'T"'... Foundation ........................ Property Line ........................ SEEPAGE PIT [ j Depth -------------------- Diameter ---_--------.. Number_..------.....___..........Rock"Filled Yes ❑ No Water Table Depth .................--.............................Rock Size _... ............ ........ Distance to nearest: Well ......-:-•-------------- ------------Foundat.ion _.................... Prop. Line ............ _ REPAIR/ADDITION(Prey. Sanitation Permit'# ---.___................................ Date ----•.................... Septic Tank (Specify Requirements) --------.............: '•--........._......_....._ f ----- j1� Disposal Field (Specify Requirements) ,� l / ._.__ �(' (' t= :fit__. ie%•__ �� --------- ..... ---...„..�..d ---------------------------------------------- --------------_-----------•------------ ----•------------•-- -----------•--••-•-------------- . I.....---------- (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. Horn# owner or lleew sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person In such manner as to become subject to Workman's Gam ensation laws of California." Signed . -.. ----------------------------------- Owner t4a By .. _ ,". •-----------•---------- -Title 021 F other than nen) R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- .._ ._ DATE .. -7:S---• BUILDING---PE--R--M--- ERMIT I5SLfED ---- ------- -------------- - __DAT --- -- - ADDITIONAL COMMENTS - ~. .__ .� •-•- l�-u --- ... .. _.. ...... .. .......................•--------- -- - ---------- ----------------- ----- _ Final Inspection by: ..__-_____ Date .---. ' . f ---•--------.. . -•--- -------•------- ------- /_--^.,7 13 2 J-� v• # SAN JOAQUIN L AL HEALTH DISTRICT 8�7a 3M