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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------- Permit � 4 (Complete in Triplicate) I -�s a---------- Date Issued _______________________ ------------------------------- ! This Permit Expires 1 Year From Date Issued _ - t Application is hereby made to tlje`San Joaquin Local 14ealth- strict for a permit to construct and install the work herein 1 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSfLOCA O ,� _ �{--__ __ d> CENSUS TRACT Owner's Name = � -F�' Phone.'z � lE�' - I- City Address ��---- ------------ -- -- ----=- ---------- ------ -- �1 Contractor's Name ------ --___.-- ___-- - -__4 --------------------------License # , _f»S_ �__ Phone Installation will serve: Residence ❑ Apartmen House'❑ Co m rcial[]Trailer Court ;E_ Motel ❑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'❑ Silt❑ Clay ❑� Peat❑ Sandy Loom ❑ Clay Loam Hardpan ❑ Adobe)6 Fill Material ____________ If yes,type _________________________ (Plot plan, showing size of lot, location of�sytbrii� W relation to wells, buildings, etc- must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public e,sewer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK; Size----------7------ _ ---------------------- Liquid Depth __' � ............. MatCapacityrTYPe eriaE___ _ No.f ComP artments.-�._ ��-.`._._..-- Distance to nearest: Well �a_ rt_____________ Foundation _/0_.___________ Prop. Line ---�- �. f . � LEACHING LINE No, of Lines --------/-______ ____ Length of each line----/:_____-_____ Total Length .._.___.__3_____ �t , 'D' Box ------- Type Filter Material ___ _________Depth Filter Material _____� ------_----...--.______-------- Distance to nearest: Well ____ _a t_______ Foundation ___%_Q___ ________ Property Line SEEPAGE PIT Depth ___ -_ _______ Diameter _ _'___`:_ Number --------/____ __�__�r__ Rock Filled Yes No i❑ 110 Water Table Depth ------------------------------- ---_---_M--•_..Rock Size --/�--�--�a---- x s to nearest: Well ____--_____f' ------------_-...Foundation -_f .f ____. Prop. Line. -------------------- Distance REPAIR/ADDITION(Prev. Sanitation Permit ----------------------------------------- Date ____----______-___--______________) ' Septic Tank {Specify Requirements) ------ ---------------------------------- ------------------------------------ ,--------------------------• w Disposal Field (Specify Requirements) -_-_____x__,__----------------------------- --------------------------------- Ir. [ e -(Draw,existing ane d_rquired 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 Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following:k= t f ) �� _ -+ 1 _ _! "I certify that in the performance of the work for which this permit-is,issue-d,' I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California. , Si9 ne'd -------- Owner t • ! BY -------//� Title a - ------- ------------ --------------- ---------------------- (If othe an owner) 4V�/,/_FOR PEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- __ ._ ______________. DATE __..- _.- . _ _7 --_______-_ BUILDING PERMIT' ___-_____ .. _ ------ --- - --- - - -- ------------------�-�= --�_...-..= --------==-=--:>:-_..,.,DATE--�=_-�-�-------------------------- ADDITIONAL COMMENTS _ ----------------- --- ^^ ---- z � - - - --------------------------------------------------- ------- ------- ------------------------------------------------------------------------------------------ + : t1 --------------------- ---------- - ------------------------------------------------------------------ ------=------- Final Inspection by: .- Date = -------------- SA JOAQUIN LOCAL HEALTH DISTRICT ,H. 9 1268 Rev. 5M