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FOR OFFICE USE: u APPLICATION FOR SANITATION PERMIT Permit No. ' (Complete In Triplicate) _ ..........I............... This Permit Expires 1 Year From Date Issued Date Issued . -��..7 " Application.is hereby made to the San Joaquin Local Health District for a permit to construd and install the work herein described. This application is made in compliance with County Ordinance No: 549 and existing Rules and Regulations- JOB ADDRESS/LOCATIO ------- _.r A 'S k.-1st ..�2 .....................CENSUS T Cf •........�....... b ��'!�s�u ...................................Phone -�-�-�- Owner's Name -•11111111._ ... - - 1111-- -- - 1 ••11••1--•1111.1111..... . Address ------------- city ........... Contractor's Name _-- .........License .�,�... Phone w. .Installation will serve: Residence ❑Apartment Houseo Commercial❑Traller Court Motel ❑Other----...----•....................•--•------•. Number of living units:------------ Number of bedrooms Garbage Grinder ...._.....__ lar size . 1111 ............... Water Supply. Public System and name ----------------------------------- ---------------------^-_....... .......... ...------............ ..... . .. � - -- ...Private Q•�� Character of soil to a depth of 3 fest: Sand n Silt❑ Gay ❑ Peat❑" Sandy Loom W Clay loam ❑ 1 Hardpan Q Adobe❑ Fill Materiol ............if yes,type ............... ........... 1 1 (Plot plan, showing size of lot, location of system in relation 'to wells, buildings, etc. must be placed on reverse slde.1 NEW INSTALLATION: (No septic tank or seepage .pit ,permitted If public sewer is available within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size............•••................................. Liquid Depth .............._ ........... i r Capacity ---------••-•----- Type ...........:........ Material...................... No. Compartments ....................... Distance.to nearest: Well --------............................Foundation ...................... Prop. Line .......................N LEACHING LINE No. of Lines ... Total Length (�] ........:.........1111-- Length of each line..---•-•--••--•--•---•--- ._...--- ................... l 'D' Box Type Filter Material ...Depth .Filter Material ' Distance to nearest• Well ........--•--...1111-- .. Foundation ...................... Pro a YLine ........................ SEEPAGE PIT ( } Depth ----------- Diameter ................ Number .... ....................... Rock Filled Yes ❑ No 0 Water Table Depth ................................................Rock Size ........................... Distance to nearest: Well ....foundation Prop. Lina - ............ ..............•-•---................ •1111-•-•--......... 1111.1111 REPAIR/ADDITION(Prev. Sanitation Permit# ........ ........- -------—-------•--- Date .........-• ---`•••-- Septic Tank S eci Re uirements[ •.......... ... Disposal Field (Specify Requirements) ............................................................................—........................•.....1111---. 1-1-11-1711.1 C f -------------------------------------------------------------............................................................-...................-•...................... . - 1111 •-••1111---1111-- -- - >- ---------------------------------- ................................. •••-•-- .._.....11,1.1 (Draw existing and required adds#ion 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:.flistrict. Horne owner or litew 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 BY ----------------------------------------- -•--------- --------------------------------- ............_-- Title - _ ------.......... ----- ....---•---------•....................... (If other than owner) I R G PARTMI:NT USE ONL APPLICATION ACCEPTED BY {? Cil ..-•- •--• -- ✓•---1111.. DATE ...' . ••-- -•---....._DATE ---- fd_ :.-- •-----. = BUILDINGPERMIT ISSUED -------------1111-- --••-•------•-•-------......-------------._....---1111.- - - � -- I ADDITIONAL COMMENTS _.-. ------------------------------------------ -- ----•-• -' --- - - --•------• _� Date_ ... � -- --- --•- . 1111. . . 1111 . Final Inspection b _--•-------•-•-•-- -. 1111...__ ..__._ . . p Y� -•-- �-•-----•--- -- --- 1111-- 1111. EH 13 2h 1-6)3 Rev. 5M SAN JOAQUIN OCAL HEALTH DIST iGT $/7h 3M