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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. �6—��•• ............................. (Complete in Triplicate) ......................................I..-----• Date issued _....... ............ This Permit Expires 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: r� -.- ---•------.. CENSUS TRACT J013 ADDRESS/LOCATION C� � ... 1 . _ . : .. nP�. . . . Name � Phone Owners � - ....................... .� Address : ...... :Y, ---- ...�.... . .' ........ - -...._.._. r _._..-.._ ...3.-- -------- - C.ty. ,Q �j ---;•.L�cense #�.��......._......,_ Phone:__.._.�.............._..-- Contractor's Name GtIG '-._.. Installation will serve: Residence [`4par#ment House❑Commercial ❑Trailer Court Numberofbuedro.oms ._.3_.:---Garbage-------- Motel r - � /J..i�i�.-vis 11 . der .__. .._...._Lot Size ..o--------------------=--r:....__.._ . , Number of living units:..-: _1.,.::.Numb - ---... v Grinder Water Supply: Public System and name -----------------__. _. :-... Private Q� Character of soil to a depth of 3 feet: Sand'❑: Silt❑ Clay ❑� Peat Sandy Loam. Clay Loam ❑ Hardpan ❑ Adobe ❑ f Ye type Fill Materia! - I s -� —�~--��-- -- - - F buildings, ,etc.:must be placed on reverse,side) (Plot plan, showing size of. .lot, location of.system inrelation'.to.wells', NEW INSTALLATION: (No septic;tank or seepage pit perrihitted if'public.sewer is availgble:within,200 feet,) [ Size:...._.:_ ............ .. Liquid Depth ..:.................... . PACKAGE TREATMENT ] SEPTIC TANK t ] Capacity .. .... Type - ---. ._ Material. Compartments ..--••- Lrn • :. :No. Co rt - Distance to nearest: Well :._.__ ...__ _..Foundation ..................:... Prop. a ...._._..---•--- No. of Lines .. . .'. Length a Le ... -- LEACHING LINE a of a da line...:...... .......... ngth Total al 'Type l Depth F� ter'Ma eria .. ........... .....•--• •- - j D' Box ._-' �T a Filter`: Maters --�-••---- -De • .;. i 3 Distance to nearest: We11 Foundation Property Line -'. --. _. DiameterNumber _ Rork Filled Yes ❑ SEEPAGE PIT [ ] Depth ....... No Water. .Table. Depth' Rock Size Distance to.necirest:,Well ..... _ --- Foundation ..... ..._ . _ Prop. Line .... REPAIR/ADDITION{Prey. Sanitation Permit# .-- =. Date ) l . ............ ':Septic Tank {Specify Requirements) --- ----' � , ------•-- �Disposol Field {Specify Requirements} ...._ -i -• ��-�'- � `` I ---------------- z 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 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: "I certify that in the performance of the work for which this perm is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed _.. :.,. . .......................... ::._ Owner .. ........ Title-. .f .-..-- .... . :.................... r (If other than owner) EPARTMENT USE ONLY APPLICATION ACCEPTED BY ._ DATE ^? ... ' BUILDING PERMIT ISSUED --------- ----- --- DA _..__ ------ •.= ADDITIONAL COMMENTS ........ ----- ........................ ..................................... -------...... ...- ----- -------- ------------- • ................. .......... ..•-..._.._--. .._. ..... -__--------.....__.._ .. - - --------- Final -- ----- Date .. -F- . Ins ection by: .... ------ SAN " _ .............. JOAQUIN LOCAL HEALTH DISTRICT „; 71723 ,4