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IOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ......... ........._.............I............. (Complete in Triplicate} Permit No. ................... .................................. / ................... This Permit Expires I Year From Date Issued Date Issued Zb." .7`..•TS k 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: JOB ADDRESS/LOCATION .:. ./;L7.Z. !/ -- .. ...............................CENSUS TRACT Owner's Name .� ...--_...• Address .......... .,02.7. �Zl.. . 1... ,`r C . . '.. .I'hone.................................... ... city '.. .,... Contractor's Name ••••�•• ...._ . .. .. ...... ........ ........... I"�.^�..... -.....------.License # .��,�,��Y ..............--- --- ----...� ..-- -......... Phone ................... Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ] Motel ❑Other ............................ Number of living units:-------- Number of bedrooms'-. r '-Garbage Grinder -__- ........ Lot Size ....!7n!........... Water Supply: Public System and name ...................... ------------------------ Private ❑ Character of soil to a depth of 3 feet: Sand ,Silt Clay� ❑ y ❑ Peat❑ .Sandy Loam ❑ Clay Loam ❑ 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,) i PACKAGE 'TREATMENT [ ) SEPTIC TANK f Size.....-_----=•....:.......:.......:...... ..... Liquid Depth .-............---.........,} f 1' Capacity -------_-------_- Type Material ---••........ ......No. Compartments Distance to nearest: Well ............ ......... Foundation ....................... Prop.. Line ......................ti LEACHING LINE [ j No. of Lines -------------- . Length of each line.. ... Total Length 'D' Box Type Filter Material . Depth Filter Material Distance c nearest: Well.- .... Foundation Li ..._. .. -— - -----=-•--••-•-----• -...:._Pro a Line . SEEPAGE PIT Diameter [ ) Depth ------------------- ._.._,.......... Number _ Rock Filled Yes ❑ No Water Table Depth .....................................Rock Size Distance to nearest: Well ............................... ...Foundation --- Prop. -Line ....................... / (Prev. Sanitation Permit�# .... ........................................ 1 REPAIR REPAIR/ADDITION Date ..............................- Septic Tank (Specify Requirements) ..................................... ---•------•-•..............................••----....--.-... ..................... Disposal Field (Specify Requirements) - .. ------------......-•-- Draw existing and required addition on reverse side) I hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin _-AJ County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local health District. (Home owner or licen- 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 Workman's Compensation laws of California." Signed ................................... .. ... Owner _ l By .. ...�: Title --- .....--... (If other than owner) •.................... FOR DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY ...... - - BUILDING PERMIT ISSUED ....... DATE .... ADDITIONAL COMMENTS A ........... .................. ......----•---........•-_...-- .......................................................... ------------------------------ -•---......•........:...........•-•-•---...--•---.............I..--•--•-- .......................... Final Inspection b !.. --- --- �. Date SAN JOAQUIN LOCAL' HEALTH DISTRICT 3 24 QE�� • E. H._ _1-'68 Rev._5M _-- 7/79 3 yr -'