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FOR OFF( OUSE: APPLICATION FOR SANITATION PERMIT I .' ..-�t.••• .. --...--- Permit No. .:....... f.7`� i` (Complete In Triplicate) ' _1-----.......... Date Issued ..//�z., I This Permit Expires 1 Year From Date 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 aunty Ordinance No. 544 and existing Rules and Regulations: r JOB ARDRES5/LOCATIO _-•.:rT_ `- -�_.."'" . ... f l. . ........CENSl1S T T _. Owner's Name ---....?�.! �,1 /1� . ... . �__L rr .. � Phone ..e ...1_ Address ............. - . .;--- City _... - :...... ... --- License # •- --- Phone.................. .......... Contractor's Nam ....<.,. c._.-_ ...._��'�. �.---• -. Installation will serve: Residence [ portment House❑ Commercial ❑Trailer Court j] 4 „ . Motel ❑Other ........ ...... ...................... s PPY Y Number of bedrooms -2 .G rbage Grind t_.-_..: .._ Size_-- '----- ... •.......:....... Number of living units:.. . ...., r, n ....._.. °e� ...............r. ..... Private ❑ Water Supply: Public System and name ........ ................ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay Q Peat❑ Sandy Loam ❑ Clay Loam ;l Hardpan*❑ Adobe [] ,_Fill Material _.......�: If yes,type ............................ Cry (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 f ] -"SEPTIC TANK i ] Size....-�.-'.---------................•-- Liquid Depth -------................... Capacity .. . Type ....... Material-............. No. Compartments -------- ............. Distance to nearest: Well .........................Foundation ..........._.-........ Prop. Line ...................... LEACHING.LINE [ ] No. of Lines. Length of each line .........,_r.. :#... _.. Total Length _............................ 'D' Box ..... Type Filter Material ....................Depth Filter Material _... -...._..._..... ................... Distance to nearest: Well ------ -................. Foundation ......----------.--.::.._ Property Line ----------.............. SEEPAGE PIT [ ] Depth -t_______. Diameter ................ Number .:._.- -------------- Rock Filled Yes ❑ No.C] Water Table Depth ------ -------------------------- ----- --------Rock Size .._.......... ................. ! Distance to nearest: Well ........................................Foundation ............ ....... Prop. Line .-._---..-•-..._...... REPAIR/ADDITION(Prev. Sanitation Permit# -------t...... .--------------------- Date ------------..--------------------) Septic Tank (Specify Requirements) ..-- rc5x . ......... ... .. ... .............. ....... ........ ............'. ........ ................ Disposal Field (Specify Requirements) ----------- - -D.-- -- a .......... --- ' ....... r (Draw exist g and required addition on reverse side) 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 licett- sed agents signature certifies the following: 'r "I certify that in the performance of the work for hick this pe mit is issued, I shall not employ any person in such manner as to beco a subi to o c an's Cio ensatio aws of California." ora. n Signed..:.. .. .G. . .t--•� . ............. ... . .. ............ .. . ......•----•-------- By .... .... ........... . - . ..._ ...r...:_._... Title �� . .......... (1 her than owner) / FOR DEPARTMLrFiT USE ONLY APPLICATION ACCEPTED BY.. - .- . �� . � .. .. __ _ DATE :. ..... ........ ....�7_.�....... BUILDING PERMIT ISSUED .-. --........yf.- ........ -----.,.",-DATE : ._.............. ................... ADDITIONAL COMMENTS .......___ ............... ----.. „ .... _r .'�-----; .=......:::........._........................................... . .. . - - ....... _.... - Final inspection by: ... . .... Date r = ..::. .........•--- I� SAN JOAQUIN LOCAL,,HEALTH,, DISTRICT 1 r- w 1 1-'68 Rev- .SM 7112.3 ►K,_r_.