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FOR OFFICE USE: FOR OFFICE US ' APPLICATION FOR SANITATION PERMIT / V (Complete in Triplicate) Permit No..- -` .. -------------------------------------------------- ..................•. --- --...------- This Permit Expires 1 Year From Date Issued Date Apptication is hereby made to.the Son 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/LO ON_�/.--.----------- --_- . . . ... TRACT..----... .: Owner's Name_... . _. c�. ,� Phone��2// .----: i��D t Address.-.-- --City- �T�-�.. .........._Zi .....-- --- Contractor's Name - --License #------------.................Phon Q-� O .i-----. y Installation will serve: Residence Apartment House ❑ Commercial ❑ Trader Court ❑ Motel ❑ Other------------------------ ----------- ( ...__Number of bedrooms_. ....Garbage Grinder------......Lot Size... - Number of living units: _../.-.. Water Supply: Public System and-name-- ------------------------- --- -------- - ----------------------------------- --------------- ------------------.Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay'K Peat ❑ Sandy Loam [ Clay Loam ❑ Hardpan ❑ 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 reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ....._Liquid Depth....:..- Q [ ) SEPTIC TANK [ ) Size...............................- ------------ - Capacity --Type-------------- ...Maferial---------------------------No. Compartments................ Distance om artments......_......,--Distance to nearest. Well---.-------.--------.....-.- -.-. .--..-.--Foundation.......... . __.......... Prop. Line----------...-.-_---....� LEACHING LINE [ ) No. of Lines ........Length of each line....... ..................... Total Length -------- ..................... D' Box Type Filter Material---...... Depth Filter Material.. ---------• ._....................... Distance to nearest: Well----------------------........Foundation.........................-...Property Line....................-.-.------------ SEEPAGE PIT [ ] Depth.................Diameter....................Number- - ---------------------------- Rock Filled Yes [:, es ❑ No ❑ Water Table Depth--•-•................ ......... ........ ...............Rock Size.. ........................ f Distance�lta nearest: Well..........................__-------------Foundation_-- ..............Prop. Line---------------.--..---- l REPAIR/ADDITION (Prev, Sanitation Permit#. ...............:................. ...............Date........=_............ ---.------:-:-} Septic Tank (Specify Requirements) ........ ....... ...........=---- --.....-. ------ ._............-- Disposal Field (Specify Requirements)... Z ...... ------------- --------------- ----------- -------------------- iE {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 licensed agents .� signature certifies the following: "I certify that i the performance of thA work for which this permit is issued, I shall not employ any person in such manner as to become yi6blea to Workman's C pens ion s off California." Signed------ -------- Owner BY •---- --... - --- --- -- ----- 7itie. ..------------ ................ j (I other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------- ------------ ........ -- ---------........DATE . ? � DIVISION OF LAND NUMBS .--.----.-..--- DATE..... ................... . ... ADDITIONAL COMMENTS._ ...... --- -- r ...-- ... ---------------- ............ ----- Final Inspection by: ------- ---------•--- - ---- ..........Date...t9- ..... EK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M