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FOR OFFICE USE: 1_Q QC1.�� APPLICATION FOR SANITATION PERMIT r .�-�J---------- -- PermitrNo. .. 7s --................. ......_........__. (Complete in Triplicate) ............. ............. This Permit Expires f Year from Onto Issued Date Issued .S�.._?� 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 LOCATIO �9 ------ ---- . . -.............................................CENSUS TRACT .......................... Owner's Name ...-• Phone 40j ! -2013 . . ..... ... .............. . Addressa �_y..._... ..Q City --.. .--- ............................................ _.... Contractor's Name ---------------- - • ........License �# . ,715 •. Phone .��s � ... Installation will serve: Residence apartment House Commercial❑Trailer Court C Motel ❑Other......--------------------•--......... Number of living units:...--____... Number of bedrooms -4 .....Garbage Grinder ............ Lot Size _..6A.".2<1 �.v.......... Water Supply: Public System and name ------------------- .._. -.....................................................Private ❑ Character of soil too depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam o Clay Loam ❑ Hardpan ❑ Adobe 117f Fill Miaterial ............ 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,) PACKAGE TREATMENT [ ] SEPTIC TANK j } Size.-------------•.......................---------- Liquid Depth ........I................ Capacity -------------------- Type -------------------- Material.--------------------- No. Compartments ----------------------� Distance to nearest: Well ....................................Foundation ...................... Prop. Line .................... . LEACHING, LINE [ ] No. of Lines ........................ Length of each line------------.------..------ Total Length ...........................L 'D' Sox ......_.... Type Filter Material ....................Depth Filter Material ....................................... Distance to nearest: Well -------------------..... Foundation ........................ Property Line --...................... SEEPAGE PIT [ ) Depth -------------------- Diameter ---------------- Number ---------------------------. Rock Filled Yes ❑ No (3 Water Table Depth ........................... ....................Rock Size ----------••--.... ............. Distance to nearest: Well ..................................------Foundation ..._...._........._. Prop. Line --------.--.-----_.--- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------- ------------ Date .................................. Septic Tank (Specify Requirements) .................... .... ........................ •• . .......... --------...... -------------------...... Disposal Field (Specify Requirements) C.�- /----•- 33 ..� ... ................ --------------------------------- - -------------- ............_-••------ ---------------...............--•------•-----•-••---......__.........._....... (Draw existing and required 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 Son Joaquin Local Health.Distdct. 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 besub ect t orkm 's Compensation laws of California." Signed ---/V--0 Q` ----- ---- ------ ---- ------------- Owner BY ----- --------- .t.� - .... ••--------- Title ---- -- el----------------------- ...... ------------------- (if other than owner) FO EPA MENT USE ONLY APPLICATION ACCEPTED BY 1 'v"i--- ------------------------------------ DATE .5 14,e 7_ . ------ 13UiLDING PERMIT ISSUED --•---------- - --....... ---------------DATE .... -- ADDITIONAL COMMENTS __.. ------------ -------------------- -- ............- •-------tl-- ------ ---------------------------------------.. .------------------ -------------- ----------- ---•- -- -------- . ...--- --------------------------------- ------------------- ------------ ------------------------------ ........................... --• . /. ----- .......... ........ Final Inspection b ..............Date ......EH �•.•• .--._. 13 21� 1--6f3 v• SAN JOAQU LOCAL HEALTH DISTRICT B/ 4 3M