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FOR OFFICE USE: --------- ----- - APPLICATION FOR SANITATION PERMIT g ------------------ - Permit No: (Complete in Triplicate) Date Issued . � -----_----------------------_---_--------------- This Permit Expires 2 Year From bate 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/LOC ON .-_- �Z.---- '----/ �0- -- -----------------CENSUS TRACT ----_-------------------- r - Owner's Name one -------- }-- -------------- ----------------------- --------------- ph _ ------------------- Address _ city Contractor's Name --- -- ---- - ---------------------License # -.I_ .3 ' Phone ----------------------________ Installation will serve: Residence partment House❑ Commercial ;❑Trailer Court Motel ❑Other -- --- ------------------------------ Number of living units:------- --- Number of bedrooms - --------Garbage Grinder .________. Lot Size --------------------------------- ____ Water Supply: Public System and name ---------- --- ------ -- -- •--------------- ---------------Private ❑ Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat ❑ � ndy Loam ❑ Clay Loam :❑ r Hardpan ❑ Adobe ❑ Fill Material _.__._:__-__ If yes, type ___________________________ I (Plot plan, showing size of lot, 105-0 ion of System-iri relation to wells, buildings, .etc, must be placed on reverse side.) NEW INSTALLATION: {No septic tank or'seepa a pit permitted public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK'- Size_++_// ____,'.____. . { ,� �t- __�-- - �----------- Liquid Depth --44 ------------ -�,1 3 k Capacity __ Oa__ _ Type _______ Material---- 'No. Compartments --A�L_-___:_--_ _.. s ,r^ istance to neares Well _ ____________ __D_(S___--(--_._Foundation ---._-_(-1�--________ Prop. Line -----il---._____;--__-_ LEACHING LINE [_ No. of Lines --__-_ "�' Length of each line__...__ __/___._-.- Total Length ,.___l6_ ---------------- 'D' .-1 . ' -------- 'D' Box _._ f-.____ Type Filter Material _____ Depth Filter Material ---------1_q_ r ` r Distance to nearest:;Well ----- a°{_ Foundation __J-D---------------- Property Line SEEPAGE PIT Depth -- - Diameter ---------------- Number __.-----------_.-.___-__-__ Rock Filled Yesl.'❑ No ❑ Water Table Depth- -____ �! ' Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------------_- REPAIR/ADDITION(Prev. Sanitation Permit# -------•------------------------------------ Date ----------------------------------) 7 Septic Tank (Specify Requirements) ----------------------------------------------------------------------------------•----------:----------------- Disposal Field (Specify Requirements) ------------------------------- ----------------------------------------------------------------------------------- ----------------- --------------------------------------------------- (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. Horne owner or licen- 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 Compensation laws of California." Signed ------ -------- ------------------ Owner 34 BY -------- �•�-__I