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FUR Q,'F!C[ U,E. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete In Triplicate) Permit No. Date Issued -- This Permit Expires 1 Year Frorn Date Issued Applicotion is hereby mage to the San Joaquin Local Health Dist&ict for a permit to construct and install the work herein described. This applicati,n '.s mode in compliance with County Ordinances No. 5499 and existing Rules and Regulations: JOB ADDRESS'LOCATION ��'i �' •fstr '/..rZ�tJ/`•C� CENSUS TRACT Owner's Name Phone Address a�yr. /zc'l��j'/��tf< ��'. City �c.e'.c-»y-:< zip Contractor's Name < ( -� � - �^ License ?y y'/} ' ` Phone �t �'1 %'tL=�. 1,, tj- r Installation will serve: Residence 0 Apartment House❑ Commercial r] Trailer Court [� Motel [] Other ......... Number of living units: l Number of bedrooms ..� Garbage Grinder............Lot Size Water Supply: Public System and nor,e _ .. Private t l Character of sci! to a depth of 3 feet. Sand ❑ Silt(] Clay❑, Peat❑ Sandy loom Clay loom (_j Hardpon [� 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 reversr: side.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ' ` PACKAGE TREATMENT [ J SEPTIC TANK [ J Size.....:............................................ . . .liquid Depth Capacity Type Material............::............No. Compartments .c - Distance to nearest: Well . ..............:.............. .,-.......Foundation............. Prop. line i LEACHING LINE ( J No. of Lines............. _. . . ..Length of each line ._. ... .. .... ......... Total Length 'D' Box............Type Filter Material... .. .. ...... Depth Filter Moterlo ........ Distance to nearest: Well ......... . ...... ..... Foundation ...........................Property line ... _ . ...- _.... SEEPAGE PIT [ J Depth _... - ... .Diameter ... .... .....Number. Rock Filled Yes 0 No Water -able Depth ... ...............................................Rock Size .. ............ ........ .................... Distance to nearest:Well. .................................... Foundation... ......:............... Pro- Line................ . REPAIR/ADDITION (Prev. Sanitation Permit tit__ ..• .. ... ........"*** .......................Date..........................._.... . . . J SepticTank (Specify Requirements) _ ._.. ...... ....... ................................ ............... ....... ............ .................................. :W CisposolField (Specify Requirements( _..... . ._ . ....... ........................................ ..................... .. ................................... (Draw existing and requ'red addIt7,Mb* �everse fide) have prepared this application bred that the work done In accordance with San J.aquln County I hereby certify that I a e P P PP Ordinances, State laws, and Rules and Regulations of the San Joaquin local Health District, Home owner or licensed agents signature certifies the following: 111 certify that in the performance of the work for which this pormit Is Issued, I shall not employ any person In such manner ett to become subject to Workman's Compensation laws of California." Signed .. / Owner r t - Title.. �?ti (If other than owner) FOR DEPARTMENT USE ONLY -------- -------- ----- " APPLICATION ACCEPTED BY DATE ._._ ^ ,. ............... .................. -- DIVISION OF LAND NUMBER - .... ......................DATE .... ........... _... . ...... ADDITIONALCOMMENTS . .. ... .... ...... ...................................................................................................................................... ......... ....................................................... ........................................ ....................................... -. .......... ;.. ......................................mo . ................................Date '� � .. Final Ins. . tion by: .....(J-,'-/C/ .`. ........... �/' ............................... '�: .... .... I �/ FH is 24 SANS JOA UIN LOCAL HEALTH DISTRICT res area etv.�i�e aM