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FOR OFFICE USE: 1 APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: [Complete in Triplicate] Permit No... -- -- -------- -- ---- 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 applicati n is m in li �� with County Ordinance No. 549 and existing Rules and Regulations: JO0155/LCATIONE�QQO �C��scrt CENSUS TRACT - -- Owner's Name . Y -- Phone-- City zip Contractor's Name ---- __-- a_ --1 r �> � 'Eft License # __3!;W Z- --Phone ----- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---- ------- --- - Number of living units: ------- _--. Number of bedrooms._-__ Garbage Grinder..-. .Lot Size -.--- Water Supply: Public System and name-.- --- ------ ________❑ Silt ❑ r� Clay ❑ Peat ❑ SandLE] Clay Loam Private L Character of soil to a depth of 3 feet: Sand Cla Sandy 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 on reverse side.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK l ....... . [� Size -��- �- �. � � - -Liquid Depth �..-.. Capacity __-PQe_ -----Type____ Material----0-6� �- __-No. Compartments 1 1— LEACHING to nearest: Well - ---- -__ �J -_---- - - - ------Foundation --1 0 _1_ -___- - - Prop. Line .--. LEACHING LINE [ No. of Lines -- --- ----- '___ Length of each line.-. e __--J- ' T - -1- .----.Total Length -.----1' 0 6 'D' Box__ ---t- __Type Filter Material_ 9---- Depth Filter Materia! y' ---- r �7 I ;. p � �3 Jr- ---- .Foundation------�--Sr' -__-- ._Property Line .---- � � SEEPAGE PIT .S ] Depth cZa neap Diameter-- } --Number--. __ ------ es Rock Filled YNo - / ❑ Water Table Depth------- --------�7c_ l - - - - --------- Rock Size. f Distance to nearest: Well_- - -- Foundation--- �- Prop. Line ----7 477..- 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-,.7 Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed 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 Compensation laws of California." Signed-- -- -- . Owner BY Title--. �c. t+' s.� f (if other thou owner) -FOR D PART ENT USE ONLY APPLICATION ACCEPTED BY DIVISION OF LAND NUMBER - -- .--- DATE__ ADDITIONAL COMMENTS--. ___ -- DATE ------ ----- ---- ----- --------- --- . ---- �� ----- Final Inspection by L --------- ------- -- ---- -- ------- --- - ---------- ----------------- EH 13 a Date2 SAN JOAQUIN LOCAL HEALTH DISTRICT ra,s 21677 REV, 7/76 3M