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. .. ............................. APPLICATION FOR SANITATION PERMIT -�/ ; ............................................. (Complete In Triplicate) Pern+�if No. .X...... ...... ........... ...... ..... This Permit Empires ] Year From De%Issued Date Application Is hereby made to the San Joaquin Local Health District for a permit to constrict and Install the work herei�ii��,, described. This application Is made In compliance with County Ordinance No. 549 and existing Rules and Regulations, JOB ADDRESSAOCATION , �-_ ... ...........„ , /...........................CENSUS TRACT ..... -. ...• ....Owner's Name .. ..... ................... .. ................................phone r Address .. .r"f.v d T� . = ....• ... Ch- .........................City ..... ........-.. Contractor's Name .., ..`� .................................................License s� . Phone . � Installation will serve, Residence 04ortmOnt House❑ Commercial C)Traiier Court ❑ Motel ❑Other............................................ Number of living units:-__-----_- Number of bedrooms ..Garbage Grinder ------------ Lot Size .......................... ... 'i Water Supply, Public System and name -... . ...............----..............--_...--•--_.........---••......•---.................Prim Character of soil to a depth of 3 feet: $and❑ Silt❑ Clay ❑ Peat . ❑ Sandy Loam ❑ Clay loam❑ Q Hardpan[) Adobe❑ fill Material ............ if yes type............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side. NEW INSTALLATION: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK f Size................................................ Liquid Depth Capacity rGh............. Type -4� .�. Materia#--------------------- No. Compartments Distance to nearest. Well ../ � ........................foundation...14�!............ Prop. Line...... LEACHING LINE [ No. of Lines J�----_---_----_ Length of each line.... ......._. Tota! length .��................. Type Filter Material ..� ... l `D' Box -----.. T ..._..Depth Filter Material ..�.................................. Distance to nearest: Well ........................ Foundation ........:...,,...� .........._. Property ! ----- -....... SEEPAGE PIT [ ! Depth Diameter ................ Number ............................ Rack Filled Yes ❑ .No Water Table Depth ' ----•...........................................Rock Sita ................................ � Distance to nearest, Well __•.....................................Foundation .................... Prop. Line ....................... !REPAIR ADDITION JProv. Sanitation Permit Date Septic Tank (Specify Requirements) ..............------............... --- ............................................................_................... ........ • Disposal NOW {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 M accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Reath 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 WorkmV ampensatlon laws of California.” Signed ..6:v- . ._..--- ................•--------------•.....--•---.... Owner ! By ...................If........----.................. ....... . xitte other than owned ! R DEP RTME T VSE ONLY APPLICATION ACCEPTED BY DAT�_ _ ............ ... ........BUILDING PERMIT ISSUED ...................... ........................................................•--- ................._DAT ..._..__.... ADDITIONAL COMMENTS .........................•......_-------------- ....... ........................................... ......._..__.._.._..............._..... ... ... ._............_._._._............_.................. ....._........._........................._. ................................ Final Inspection b ......it.; ----•----- � y . .. ... .... ................. .......•-----... .....Date -'�'---��... ..� ..---._.. ... ....-..I...............•-----.. _....................._ .. ............. 13 2!, 1-613 Rov. 5�4 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h