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N/ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ................. r. (Complete in Triplicate) Permit No.. " .............. .......................................... ..// Date Issued ....................... This Permit Expires 1 Year From Date Issued Application is hereby mode 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 ounty Ordinance No 549 and existing Rules and Regulations: JOB ADDRESS/LOC CENSUS TRACT .......................... Owner's Name .%C. ........ .......................... i Phone .................................... r Address . !�. / -------- - ----- --- --City ... .. —s l r_J Contractor's Name _.. -License# ....... Phone .............................. �..... . Installation will serve: Residence[)Apartment House Commercial (:)Trailer Court 0 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 L-R Silt❑ Clay, ❑ Peat❑ Sandy Loan 0] Clay Loom ❑ Hardpan❑ Adobe ❑ Fill Material ...... ..... If yes,type............................ (Plot plan, showing size of lot, location or system in relation to wells, buildin,-3s, etc. must be placed on •everse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,' PACKAGE TREATMENT [ I SEPTIC TANK[ I Size........................_-._-................. Liquid Depth .......................... Capacity - Type ..... .............. Material...................... No. Compartments ..................... Distance to nearest: Well ................ ......•............Foundation ...................... Prop. Line...................... LEACHING LINE t ] No. of Lines ... Length of each line ........._......... ...... Total Length ............................ 'D' Box ...... .._. Type Filter Material --.---Depth Filter Material ............................................ Distance to nearest: Well . ...................... Foundation ............... ........ Property Line .................... SEEPAGE PIT ( J Depth _. Diameter ................ Number . ... __ _....... Rock Filled Yes ❑ No Water Table Depth Pock Size .. -------------------- Distance to nearest: Well ... ....................................Foundation ..... ...... ....... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ........__ ........ ................. . Date ............................. ....) Septic Tank (Specify Regviremen;s) .... ................................ ................................................................-............_..-- Disposal Field (Specif Requirements) _. ......................................... .... ..... ....... ................. - •......... .. r r�Zy _......_. ..... ......_................................. (� (Dro•N existing and required addition on reverse side) I hereby certify that I ho.e prepared this ap.�Iiceiion and that the work will be done in accordance with San Joaquin County Ordinances, State laves, and Rules and ceoula!ionr of the Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the wo k For which this permit is issued, 1 shall not employ any person in such manner as to become subject to !rkman's Compensg iorr1 f Californig." Signed (( ..... .. / Z /T-- ... �+q.c Title I Owner :.. �t:.lr/ .. ay (if other'hon ov net) V FOR DEPARTMENT USE ONLY - - / •� `S? -=- - DATE �./-. APPLICATION ACCEPTED BY ' ''Y" ... ..........J _ 3UiLDING PERR41T ISSUED ._-.- ... .... �. . . _... _ .. .DA ......... ... ............. .. ..... ' nr- n. .. . .- ` ....- . F;r+ol InSp2Cti�n by �.i�'2%J'/��'�z�,.�"�^ " '.. ... Date .............. ...... JGAC:JIN LOCAL HEALTH DISTF.ICT r 5�: