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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............ .......... .. - . ..... Permit No: ................. (Complete In Triplicate) t ------------ . ............................. -- Date Issued ... This PermWExpires 1 Year From 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA ION ._.... �� - - r`� CENSUS TRACT ----••-----•- Owner's Name •--••--•-- ....................... ...... Phone ..................................... ......_. I Address �1 . City Contractor's Name 4 ;.--•---•--•--• License # �. _ Phone - Installation will serve: Reside e❑Apartm'ent House i] Comme al❑Trailer Court 0 Motel ❑Others:_ '*-- Number of living units:..... Number of bedrooms ----)--.-._Garbage Grinder ------------ Lot Size _-_.-7................. ............... Water Supply: Public System and name .----•--•-•--•-•-•-• .••------.......-------------------------------------------------------•......_- ------Private Character of soil to a depth of 3 feet: Sand'E] Silt-E] Clay ❑ Peat❑ Sandy Loom J� Clay loam ❑ Hardpan ❑ Adobe 0 Fill Material ......._.... If yes,type ............................ • r (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 rf pubUcc see we rl's available within 200 feet,l PACKAGE TREATMENT [ SEPTIC TANK Size.. Liquid Liquid Depth ....- ..._.._.•._._2. Capacity�rrZ�?8 _ Type �_�____ Material - .-..__ No. Compartments __. „_........ i oZ Length of F., IineFo�d�v�. Notal LenothL,..IE?r? ..._...__1 Distance to nearest: Well ;........ op. Line ______ _________,€ LEACHING LINE [ J/ No. of Lines 'D' Box;-_-I...... Type Filter Material ___•_.$__R------Depth Filter Material ....... 7._.............__._...-......... Distance to nearest: Well --------270......... Foundation ____ Property Line. ...,.............. �T Rock Filled Yes Na a SEEPAGE PIT [ ] Depth ____________________ Diameter ................ Number ____.......... ............. ❑ ❑ Water Table Depth --------------------------------------------•----Rock Size .- = ............. Distance to nearest: Well ....... ..•.::.................................Foundation .___._._............ Prop. Line ....._.._.._._.__...__ REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date .................................. SepticTank (Specify Requirements) ............................................................. .........-•-.............................,.......................... Disposal Field (Specify Requirements) ...........-...... ......................... ................................. ........................... ...............................=....................._....... --•-•---------------------------------=-------------------------•------------- --------------- '. ............................................................................................................ ..------------------------..----------------------------------.:.................................. I' (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 Joaquln County Ordinances, State Laws,':and Rules and Regulations of the San:.Joaquin Local Health District.home owner or licenL 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 manneir as to become subject to m n's Compensation laws of California." Signed ......................... . .Owner BY -------------------- ---- ---- title (If other than owner) FOR DIEPARTMENT USE ONLY APPLICATION ACCEPTED_BY:_:. .. _•'•�_. ...- . --•-•--•-- _.. , . ------------------------ --------- DATE ---- b' .` -•------------ _ BUILDING PERMIT ISSUED -__..._.�.................... . -- •------•:------•..............................•-�••--•-••----...._.DAT _._......_..-•--•--..... ADDITIONAL COMMENTS __________________________ .......... .............................................. -- ---------- ---••-•-•-- - , ...................•-••-.-• -------------` •-----------.•-.-_..------•--•---------------------------------------- Final Inspection by: _ _ �..e. ... ---------------------•------•------....------------ --------.....----------Date �6_"'err'. -' ;- ----•-----; SAN JOAQUIN LOCAL HEALTH DISTRICT 4 r E. H. 9 1-'bB Rev. 5M