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FOR OFFICE USE: . ............. .... APPLICATION FOR SANITATION PERMIT �/ Y I (Complete M Triplicate) Per No. .. 7.:/�,�.... k........:................................................. This permit Expires 1 Year From Date Issued Date Issued .. .:� .Z 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 ...... ........... ;�....................CENSUS TRACT ................. :._. Owner's Name kft*��a. ....................................•- Phone .................................... Address . .". ��: :_' !'�-e.; ...... City _. ..........:.. .....:.::::......... *.......:............ Contractor's Name:........ ._._._ . �... `.. .,.........License # AZ Phone .............. , r Installation will serve: Residence I]Apartment H seQ Commercial�QTraller Court -0 Motel Q Other ... .... .. .. ....�. e -. Number of living units:............ Number of bedrooms.............Garbage Grinder ............ Lot Size ............................................. l Water Supply: Public System and name ...........................:.............. ......•---.._._._..................................................PriPri vate Character of soil to a depth of 3 feet: Sand n Siltf:] -Clay E] Peat Q Sandy Loam lay Loam Q Hardpan Q -Adobe-Q 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.[ ' NEW INSTALLATION: (No septic tank or seepage-pit permitted if public sewer is available within 200 feet,} I PACKAGE TREATMENT [ ] SEPTIC TANK-f ] •Size................................................ Liquid Depth ......................� Capacity .................... Type .................... Material-----------........... No. Compartments .................rte Distance to nearest:-Well--n...............................Foundation ...................... Prop. Line .._..........---•-� LEACHING LINE [ ] No. of Lines .. g � g Length of each line._.__....:.............. .. Total Len th .......................-:.. 'D' Box ............ Type Filter Material ...:..:.....:.......Depth Filter Material ........ _:.:.:-... " Distance to nearest: Well .... Foundation ..... Property Line ..... .:............... e SEEPAGE PIT [ } Depth ............:.:....., Diameter. ................ Number .......:...................... Rock Filled Yes 0 .No.Q WaterTable Depth ..........•.....................................Rock Sze................................ Distance to nearest: Wel ........................................Foundation --------------- -. Prop. Line ........... REPAIR/ADDITION(Prev. Sanitation'Permit r# ...................................... .. Date .................................. . Septic Tank (Specify Requirements) .....................-.---..._.. z .._......................... ......_........... Disposal Field (Specify Requirements) ..............1 A..a...... .......... == ................................. ....•-------•---------•---•--•-.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 Men- 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 manner as to become subject to Workman's C mpensation laws of California." Signed .........................:................ ........ .....--- � . Owner �V . T _ ...... By ................. .... , itis .:.._ :......... . .. .. ....... ...... (If other than owner) FOR TEPA TMENT USE ONLY APPLICATION ACCEPTED BY ...... : .....:.....................:............................. DATE .�_.�f..�.�-�- ............... ' BUILDING PERMIT ISSUED .DATE ADDITIONAL COMMENTS .......................................... ...... ................................................... .... :.....:....:.........._....:...........•• -••........._ .::....................................................... ...--•--•---.....:_......................................• .............................. . ............. ._.. I �. .. Final Inspection b • ........Date . P y' 4. :. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 24 1.'68 Rev. 5M 7/72 3-M