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FOR OFFICE USE: APPLICATION FOR SANITATiON PERMIT CNo. (Complete In Triplicate) Permit No. ...............•... . (Complete .............................•........................... This Permit Expires 1 Year From Date Issued aued ...� Date I - .......... Application is hereby made to the San Joaquin Local Health District for a permit to constru.t and install the work herein described. This application is made in compliance with County Ordin nce No. 549 and existing Rules and Regulatlot,. JOB ADDRESS/LOCATION l J �.... p- „ .-. 0 _ . . CENSUS TRACT . Owner's NameV Q .. one - ... Address 73 .>�...... city .. Phone 1"a.6 Contractor's Name .................. ... .......�?'<�...............license# ?.7.. y�...... .-�6oJ... Installation will serve: Residence Apartment House Commercial ❑Troller Court O Motel ❑Other.............-................... .......... Number of living units:..... .... Number of bedrooms ....E?.....Garbage Grinder ............ Lot Size .......-4,------------ ---- Water Supply: Public System and name .............................•....._............. ..._......._.........................•................Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Q Clay Loam ❑ Hardpan❑ Adobe 19 Fill Material ............ If yes,type............... ............ (Piot 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 i, public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size................................................ Liquid Depth .......................... Capacity -......---..... Type .................... Material...................... No. Compartments ...................... Distance to nearest: Well .......................... .Foundation ......... ............ Prop. Line ......................J LEACHING LINE [ ) No. of Lines . ..._....... ......... Length of each line _.................. ...... Total Length ............................w 'D' Box ............ Type Filter Materia! ....................Depth Filter Materiu ............................................5 Distance to nearest: Well ......................... Foundation ........................ Property Line ........................ (1� SEEPAGE PIT ( J Depth ......... ......... Diameter ................... .............. Number ............................ Rock Filled Yes ❑ No Q 1 Water Table Depth ................................................Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... P REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ...........•....................... SepticTank (Specify Requirements) .......... ................f.......................... ....................................................-..........._............... Disposal Field (Specify Requirements) ......�Q ...... � k� 4:�J. .. ......... . .. - ... .. Y � r... ... ...... .............................................. . ........................................................... _ ..............._............................................................................................ (Draw existing and required addition on reverse side) 1 hereby cert:fy thot I have prepared this application and that the work will be done In accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local V.ealth District. Home owner er lit+n- 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 parson In such manner as to become subject to Workman's Compensation laws of California.” Signed ... . .. ... .........4tn Owner By4f'otherowner)_ FPR DEP RTMENT USE OlJLY APPLICATION ACCEPTED BY T . ... GrZ.�.. _ DATE - / BUILDING PERMIT ISSUED /.. . _ DATE ................. .............. ADDITIONAL COMMENTS ..... ...... .:............................ _. ..... ... ... Final Inspection by. / ....... �,L�! .. ... ........ ... <!.jt Oate / r 01 13 21-1 1-611 !lay. 51.1 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M