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FOR OFFICE Use: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) =Perm€tNo. . ......... This Permit Expires t Year from Date Issued Ddte 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 compliant with County Ordinance No. 549 and existing Rules and Regulations: s JOB ADDRESS/LOC N .......... ENSUS TRACT .... Owner's Name .. .... .. .. .. ....... .. .. _ _ ..._ _ Phone I -._................ Address .__..l�A)----- - City ...................................... Contractor's Name ....... license # ��_3 G 3—�� •- 2...... Phone Installation will serve: Residence(Apartment Houseo Commercial❑Trailer Court f Motel ❑Other-------------------------- Number of livingunits _.. Number of bedrooms --.Garbage Grinder Lot Size ................. Water Supply: Public System and name` 4�: J _ .Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam {]. Clay Loam ❑ Hardpan 0 Adobe fF€ll Material If yes, type j (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,) �� PACKAGE TREATMENT [ ] SEPTIC TANK ] Size.__.......••--.--•_. ..... Liquid Depth .......................... [v Capacity ------------•------- Type ----- -- -_.. Material---- ....... No. Compartments Distance to nearest: Well ------------- --- -. __........Foundation ............ Prop. Line ... ...... ___ LEACHING LINE [ j No. of lines __ __________•-----._- Length of each line---------- ............... _ Tota! Length ......• .....- 'D' Box _....._._ .-Type•Filter--Material--". ----��Depth .l�€Iter Material ----------------•--............ Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ \ SEEPAGE PIT [ 3 Depth -------------------- Diameter ..._.----------- Number ----- ...................... Rock Filled Yes ❑ No ❑ Water Table Depth ..................---=-=-------------------_--Rock Size :::— •r"-`"-............... r Distance to nearest: Well -----------_--_--- .. _...Foundation .................... Prop. Line ........ ............. REPAIR/ADDITION(Prev. Sanitation Permit# ------------ ----__ _ - ------- Date ...................... ----------- Septic -- Se tic Tank JSpecifV Requirements) . rr Disposal Field (Specify Requirements) ._.__..l_'...3 3 ,25 ..... ,............ --- ----- ----:- ---- ------••--------------------- --------------------•••------------------ .--------- - -- ---------- (Draw existing and required addition on reverse side) I hereby certify that 1 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:Dlstrict. Home owner or lican- sed agents signature codifies the following: "1 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 beco sub'ect to W kman' Compensation laws of California." Signed _. -r] ,v................... ......-------------_-_---- Owner BY 7 --- (€f o er than owner) �.. --------- -------------------------- Yitle R DgPARTMENT USE ONLY y. APPLICATION ACCEPTED BY _...._ S" /G -------- DATE ...... ...... ...�---->> ----- ItDWG PERMIT ISSUED ------------------- ............_DATE -.._.._............. ADDITIONAL COMMENTS ............................... K . ...------- -----...............................................•--.—------------ ........ ----•---- --------------------- Final Insy:b p Y: -•-----•------ • --. . .--- - --- - -- -•---•-------•-•-•-------• ----------------- - --- - -----------Date ....)r/1.�.��...................... EH 13 2 —6 i v` SAN .JOAQUIN LOCAL HEALTH DISTRICT 'f 8/7h 3M � K r