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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �y Permit No�. ..��.' tT'.._ (Complete in Triplicate) / a �O Date Issued ............... This Permit Expires 1 Year From Dats issued 1 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/LOCATI _.7..;...._....-,....�. . �! ^- - - - +�. . .... SUS TRACT . - - Owner's Name 0 Address ---- ..........o�-- Q .. -- / -- �J City - Contractor's Name ....... - ! WPLicense # Iff.22Z,-� Phone ............. ld/1 �✓... . . .._. .._ ... 1 'installation will serve: Residence [�<partment House[] Commercial QTrailer Court I❑ Motel ❑Other 1 Number of living units:..-.----.-- Number of bedrooms 1......-Garbage Grinder _.... Lot Size ....�.._.----..Pri-`------- --- Water Supply: Public System and name -�--------------------------------------...----------------------------------------------------- Character ---.....-----••---- • - - --------------------- Private [� Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom 1 Hardpan W Adobe Fill Material ---------- if yes,type------------------------- -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) V 1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,' O PACKAGE TREATMENT f ] SEPTIC TANK{ ] Size-.........................••••.------ ---... Liquid Depth _............................. Q Capacity --------- TYP.S��:_---------- Material...................... No. Compartments ................. .._-- p -- ---- ---- Distance to nearest: Well ----.-------------------------------Foundation -_--------------- Prop. Line.---------------------- Length of each line.... ----- Total Length :---...-------------------- LEACHING LINE [ ] No. of Lines ..................... .. gt 1 'D' Box ............ Type Filter.Material ...............--.Depth Filter.Material.-...................................... ..... Distance to nearest: Welt:.-------- ----------*_.A Foundation ----- - Property Line. .._........-.......... - ----------- De Depth ... Diameter .----••----_ii- Number . - --------------- Rock Filled yes '❑ No i❑ SEEPAGE PIT [ ] p ----------------- r WaterTable Depth .........+....................................Rock Size ------------................... 1 Distance to nearest: Well ....:.._-.:_.........:_ ...Foundation ............"....�: Prop. Line ..................... ' REPAIR/�GN{Prev. Sanitation Permit# ............................................ Date --- ----------- -1 ------------- Septic Tank (Specify Requirements).-------... --------...------•---- ---------------- - - ^-------- Dis al field (Specify Requirements) ....Qbn4� •• •- '*°'r" �'�,,gTQ ` -4- .I ' 1 a ® ' P �. . - ------ ----------- - (Draw dkisting and required addition on reverse side) 1 I hereby certify that I have preparedthis 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: 1 "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 'ect io Workman's Compensation laws of California." Signed ......... -- - ------- Owner ---- -- .._.----- -• Title .. - -/L,q't-- (If other than owner) FOR DEPARTMENT USE ONLY qz a..... 1 APPLICATION ACCEPTED BY- ....... . . .... n DATE y - f- ` _... - - - DATE .. .................... BUILDING`'PERMIT ISSUED .................................... ........................._._........................_......... ADDITIONALCOMMENTS .................-........ ........................................... - -^ - - --•------------- - ------------------------------------------ - - - - ------.... ................. .............. .. - ,} } Date ..........:.f Final Inspection by: .--� .....----.�. . ..... �'t'�-•---..........._---•-----....._.._...-.... SAN JOAQUIN LOCAL HEALTH DISTRICT ' E. H. 9 1=68 Rev. SM•