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r FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT t'.......... ............................................. Permit No. ..�3.`�� (Complete in Triplicate) This permit Expires ] Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local 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 existing Rules and Regulations: WU JOB ADDRESS/LO N .... I ...._,_. / L .._._ .. . ... ..-•-1..................CENSUS TRAq .......... Owner's Name ........ _ ....; ... .. -- ---- -------------------- � •-•---.._ ... ------.... rr .� Phon .,.: Address ...._ �. �.. - 4U 1�- CITY .... ... Contractor's Name ... C..'....__ .License # .� -- :-- Phone ._. Installation will serve: Residence [ A artment House Commercial []Trailer Court `]: Motel ❑Other .................... ......... F 2 Number of living units:........(-.- Number of bedrooms ...:...Garbage Grinder ........ Lot Size .......:....------'._......... . ..........,. Wafter Supply: Public System and name ...................'..................---------------- _ Private ....... Character of soil to a depth of 3 feet. Sand tD Silt❑ Clay. [I Peat 0 Sandy Loam'o ` Clay Loam Hatdpan Adobe.E] Fill Material ............ If yes,type ------------ ............... (Plot plan, showing size of lot, location of.,system in relation to wells, buildings, etc. must be pldced;.ori reverse side.) I NEW INSTALLATION: {No septic tank or seepage,pit permitted ifgublic sewer'Is available within 2.00 feet,J . �. PACKAGE TREATMENT ] SEPTIC TANK f ] Size_______ ....................._---__•--------.... Liquid Depth ......................... - . T e Material ....... No. Compartments . Capacity ............... Yp ................. ----•----.:.... _ .....................- Distance to nearest: Well ---•--:-•--..:..Foundation .........�..:...._ __. Prop. Line ....................... - Length of each line Total l ten tS ... LEACHING LINT~ � [ ) No. of Lines ---------,--•---•_-•-- g ---• g ---- ........ - D' Box . Type'Filter Materials. ..`.:...::.:..:.::Depth"'Filter Material _._.....__••-- -_-- Distance to nearest.• Well Foundation .. • Property Line- ` SEEPAGE PIT ( J Depth ....: ............. Diameter ....:.:!....... .Number ._:_.:.........: .... Rock Filled Yes ❑ - No.0 • Water Table Depth ---------------Rock Size................................ :_ Distance to nearest:.Weli ------.... ______________________Foundation ..... Prop Lino .__. ... _. REPAIR/ADDITION IPrev. Sanitation�Permit# ........... ...................:............ a ___.,__-• --------- ........... Date ..:.. .........................:...... ..... .Septic Tank (Specify Requirements) ........... ...:.......... ................... ...... . .:....- ---------- i Disposal Field (Specify Requirements) •-- --------•- ••-.. -------- -- :. ... ----- . . , Draw exist:. and _.:... ..- _... - ------=--- - ;.... ................................ex _ 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. Homeowner or licen- sed agents signature certifies the following: �...,.•.; -..., �- $ - I "I 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`: cation I sof California." Signed ............... ...---• ... ..I .. - Owner ---- -• By Title ..._.......-•••..... ....._ (if other than owner) : k FOR DEPARTMENT USE"ONLY l APPLICATION ACCEPTED BY . ........................ ~�...... • ` ... ..........:. BUILDING PERMIT ISSUED . .._..._ E ._....._.-.- ........... • DATE _ s/ = ---=------------------- - -- --- --- ----- --------- DAT ` ADDITIONAL COMMENTS " .. .'..................... -----•----------------------- -=--:......-...............---:................_.:-•----------•-- •--•-•--• -----•• •. . ••--••--- •--• ----•-•......._-..._.....-----•---•--•---- .................................................... - ...... .e ... •.... ' ._.___._.. --- .. .-. •r,•-'�F• y._. .-- _ -- .�• ._-r• •• _ ----._........ . . --/ a 7 ......._.._. ..• -- _ SAN JOAQUIN _LOCAL HEALTH DISTRICT 13 24 ,_-,.a De., a,u 7/723 M