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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...........A.......................•- � X33 (Complete in Triplicate) Permit No. . __.._'------_----- ......................................................... .............. This Permit Expires ? 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 application is @ .�cgmpliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .... ......,. / ..:4/C ................. !W......................CENSUS TRACT .......................... Owner's Name .. 4 e ...... .......................................I.....................................Phone .................................... Address ......._._716.3-------- _._.. _ t . ........ .... ..�. ...........:.... .....:City ... .... ._3E .......................................... " Contractor's Name ie"4-4 4:V.......: � ,........•...................License # . '' a I.. Phone Installation will serve: Residence Apartment House C1 Commercial❑Trailer Court C] Motel ❑Other .................4.......................... 4- Number of living units:... ------ Number of bedrooms ......Garbage Grinder/°o..... Lot Size .1 Com' t Water Supply:-Public System and name ...... --..•..elf ,................_.............•...-•.•--......................:......Private Q Character of sail to a depth of 3 feat: Sand'] Silt❑ Gay ❑ peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan[] Adobe Fill Materlal ............ If yes,type ............... ............ (Plot plan, showing size of lot, I'cation of system in relation to wells, buildings, etc. must be placed an reverse side.) 4 NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT F ] SEPTIC TANK :-------- Liquid Depth ........ ................::�! Capacity C *0------- Type Material. No. Compartments ...............(0 Distance,to nearest: Well ------'I�r 11 ...............Foundation ... .......... Prop. Line.........-._. LEACHING LINE { ] No. of Lines ...__—------------- -_ Length of each line.._. ._....... Total Length .� .. . ....-_...... f I:iD Box ..,1.._... Type Filter Material� i.. .Depth liter Material ... .................................. Distance to nearest: Well ......A&.......... f=oundation .... ...... Property Line .%3�............... SEEPAGE PIT { 13 Depth 014 ......... Diameter . Number .. .1.................... Rock filled Yes - N6-10 y Water Table Depth ................ Size . ,, s ........... Distance to nearest: Well ..........W.OAO..................FounclationT,6-•---•....... .Prop. Line................ REPAIR/ADDITION(Prev. Sanitation Permit# _ Date ................... � I Septic Tank (Specify Requirements) .............. ................................................. .................... ........................... Disposal Field (Specify Requirements) --------•-------•------------- ..................................... .....................---------------------------.................. ---------•--------------------------- ---- .._..._.............--.... --•.._.......................-----..-.--•------------ .......... ----•-----------•------- ---------------------------------- ---- ......................................................I................... .............. (Draw existing and required addition on reverse side) . 1 hereby certify that I have prepared this application and that the work will .be done In accordance with San Joaquin r 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, 1 shall not employ any person in such manner as to become subject WorkmaWs Compensation laws of California." Signed -----------efother"than --• ••-- ---- -- -- . . ........--- Owner BY ----- Title --------- ownerl PEPAPXMENT USE ONLY APPLICATION ACCEPTED BY _.."_._ --. /[,� ____. _. ---- --•-•------ ---••------• ------------ ----------- DATE .._.... _/_� ._ ........._.: BUILDING PERMIT ISSUED i DATE - ------------------ ADDITIONAL ---- ADDITIONAL COMMENTS --------.---r_-.-- , - -- -:- - - -- ------ - - - --- -• -------------------------------------------------------------------..._ ---------------------- ------------------------ •-- ...................---•-------------•- .................................... -----------------------•------ ...... ---------------- ?�/- ... -----------..---------•-------•----•---....._..........------. ---.......-_....Final Ins ection b _ _ ••- --- .._.p Y- ------------•�-----�- • - - -- • ....................._._..---•-•------------ Date ..... /�-...�.�._..�.----- EH 13 24 1--6 3 Rev. 5M SAN JO UIN LOCAL HEALTH DISTRICT 3M k.