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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .......... I., .................. ;/ ............ .. I (Complete in Triplicate) Permit No......... .......... ....................................... •--•••••=•-•.. This permit Expires 1 Year from Date issued Date Issued Application is hereby made to the San Joaquin Local Health bistric for a permit to construct and install the work herein described, This application made,"yjvq c yl� , 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT1 N .��..� )w......Id ....l(I raCENSUS TRACT ................. Owner's Nam ... ............. •.r�+.`�...J FGA ........ • ................. Address ...........,..d.t ..... �._....�... %..:'�._... ne .. .......... 0 .............. City . . .. ._._........ .. Contractor's Name / License # f•�� ..3. �- Phone `....................... installation will serve: Residence ❑ Apartment House Commercial OTratler Court 0 ti , 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 El Peat ❑ Sandy Loam Clay Loam .❑ I Hardpan ❑ Adobe [] Fill Mpterial ............ 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,) oQ PACKAGE TREATMENT [ ] SEPTIC TANK j ] Size. I .. ..................... .................. Liquid Depth ................ I.......... Capacity ................... Type ............... :._ Material_ ................ No. Compartments ...................... `�. 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 Lyne ........................ SEEPAGE PIT [ ] Depth ......... Diameter ................ Number ........ ..............._ Rock Filled Yes ❑ No i❑ Water Table Depth ...............................................Rock Size ............... Distance to nearest: Well ................... .Foundation .................... Prop. Line ................. REPAIR/ADDITION (Prev. Sanitation Permit # ....................Datec .. .__........•..._..-..:....----•-•] � Septic Tank (Specify Requirements) ....................... 1 \14 ! ..... Disposal Field (Specify Requirements) ...�� G�! U �% 1119 900 .................. _.... ....................... ..................... .off-:L�.a... � � • .— -- '' jDraw e i ting and requi ed a ition on reverse side) ' I hereby certify that I have prepared this p p plicatlon and that tho 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 permit is issued, I shall not employ any porson in such manner as to become subject to Wo kman's Compensation laws of California." Signed...................... J._...... .... .. Owner By ............ ............ Title.. — (If other than owner► y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .............. .. DATE 1, . ................. DING PERMIT ISSUED ..:................. - ................... ........ ................ ...................... ,...DATE ............... . ADDITIONAL COMMENTS - -...................... ............ ............ ......... Final Inspection by:.. .. .. ... ...................... . .. .: _.... ate%l.�.c .../...1........ SAN JOAQUIN LOCAL HEALTH DISTRICT ✓ \LE. H. 9 1-68 Rev. 5M .� Z,