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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ". Permit No: . (Complete in Triplicate) Date Issued .................... .......................................... This Permit Expires 1 Year From Date Issued r Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations- CENSUS C�Nsus TRACT JOS ADDRESS/LOCATION ........................................ ... ...............:.......... Owners Name l....l..._.. ,... :............................:....... Phone , 9s1....... :. >`.. City Address ........ ..--•. ............................. Contractor's Name ........_ p�}-1 _C .l.�_ .: .. f2.A.1� JaQ..e=._._.....License Phone •- Installation will serve: Residence ❑Apartment Houseo CommercialT railer Court Motel n Other .......... .....' ......:.... Number of living units:............ Number of bedrooms ............Garbage Grinder --- ........ Lot Size ..._.,. .. .... ._...........__-. Water Supply: Public System and name ......................................`............................................ --------- --....... Private Character of soil to a depth of 3 feet: Sand 0 .. Silt❑ Clay ❑ ' peat Q Sandy Loam ❑ Clay Loam D Hardpan ❑ Adobe 'Q. 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.) v NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) t, PACKAGE TREATMENT [ ] SEPTIC TANK,W Sia®----.-- ..J ... ....................... Liquid Depth .............. Capacity pe . .. Material..-� .c-.- No. Compartments .. .............. G r Distance to nearest: Well Q..01f............Foundation .._..ls ........... Prop. Line ...��... ........ LEACHING LINE No. of Lines ........ _.......... Length of each line....... Total Length .._x.53.0........ .....-. h 'D' Box .-- Type Filter Materia[ Depth Filter Material .......��J,.-....................... . Distance to nearest: Wel! , ...... Foundation ...... . Property Line __4L......... .................. r �'r � .......-�Rock�F.illed_ ,Yes � No SEEPAGE PIT �Q Depth ....�.�..------. Diameter _.I�.. ..------- Numher .......... ......... � ' r Water Table Depth ........._.. �.. ........Rock Size :t i Distance to nearest; Well I0A..__.t...............Foundation ...f.57_.�_.... Prop. Line ... , ---- _ REPAIR/ADDITION(Prey. Sanitation Permit# .... ---------- --------•--••-•..... Date .................... ' Septic Tank {Specify Requirements] . ............ -------------•---•--•-•-••-•--------....--•-----•------...........-=----._..-----...----- Disposal Field (Specify Requirements) ....................................................................................-........................................ ...............•---......__ ......... _._........_...---•--._._..............._......._......i....................... .. ........................ ........................................... . -......-----.. .........................t. .......:...................................................................................... (Draw existing and required addition on reverse side) I I hereby,'ceitify that i have prepared this application and that the work will be._dono In accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the-San Joaquin local Health District. Horne owner or [icon- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, ,shall-riot employ any person in such manner bis ., Z, as to become iu6ject to 1Noarkm'an s Compensation laws of California." . Signed ..----- --- �-�� ....................... OwrTer. a ` _ By ..........-- ...... ................ ........................... �it(e ......._._....... Xf< , ' (If r than owne`r}'-"� Q. FOR DEPARTMENT US ONLY APPLICATION ACCEPTED BY ..... ... .......................... .....--.. DATE . BUILDINGPERMIT ISSUED ............................................ ............................................................DATE ....................................•...... i ADDITIONAL COMMENTS ....................................................... --- - - _• ' . .... ................ .............. . ..........._...... ......:r7......... .. ...... . ....... ;� ......_ .� - = - _-------------------------------- - u . .... .... .......... . ............ ...... ..... . ..', .^. .............. :........: ......... .. .......... :.. --•-- ............Dote Inspection b . • • ------- SAN•JOAQUIN.LOCAL H . ALTH DISTRICT - 13 24 1abs Rev. 5M 7/723 M