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FOR OFFICE USEr APPLICATION FOR SANITATION PERMIT Permit .................. ............... ...................... IConeptato to Trlpiicatol No. .7...........Z.. ............... ...... ................................ This Permit Expires 1 Year From Date Issued Date Issued G6 ........ ? Application is hereby made to the Son Joaquin Local Health District for a permit to tonstrud and install the work herein described. This application Is made In compliance with County Ordinance No. 549 and existing Rules and Regulations, JOB ADDRESS LOCATION ... . / ... �.�.C .. .. . CENSUS TRACT .......................... F.- Owner's Name .... .. ....... ............. Phone ................................. Address ....... ........ .. �T��lr4 i'.................City ---........... 6 . . ... Contractor's Name x� r_.d.._.�...� r r s ... ....,r,!W..4.11cense # . .1'� . Phone _ .(... Installation will serves Residence❑Apartment House(] Commercialraller Court 0 Motel❑Other....................•---.....�....--•••-.... Number of living units-•- -- ... Number of rooms ..: . --- rba a Grinder .:-t5q" Lot Size -0-f.a?z..... •-- P - Water Supply: Public System and name ...... - .... ..................................................... Prlvpte�' Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Q Hardpan❑ Adobe 0( Fill Material ............If yes,type............... ............ (Plot plan, showing sure of lot, location of system In relation to wells, buildings, etc. must be placed an reverse side.) NEW INSTALLATIONS (No septic tank or seepage pit permitted if public sewer Is available within 200 feet,) { ] �a...Z1.: .. Liquid Depth � ..! PACKAGE TREATMENT SEPTIC TANK Size. .... .......... ..... ............. " Capacity Id4W"'Type��t.�,G Material_ _...._ No. Compartments ...X........... .� Distance to nearest: Well' ...-,,$7V.°...................Foundation .... ...... Prop. Line .:4......... _...U, k LEACHING LINE Na:of lines ........� ...---.--•- Length•of,°�ch line....:..y l s..... Total Length .R�. -::. .............n 'D' Box .. '_ Type Filter Material ..lt ...#lepth Filter Material . .,hY.................................` o! _ • , Distance to nearest: We#1 . G... ........ Foundation ..•......... Properly lies .�........... SEEPAGE PIT Depth Diameter :.�� Number ....I .................. Rock Filled Yes Ck No Water Table Depth �� .�....... .....................Roc k Size ...f,-2..�....�.......... ,- Distance to nearest: Well . .,�ais� .......................Foundation .... . ............ Prop. Line .. .................1 # REPAIR/ADDITION(Prey. Sanitation Permit# ............................................ Date .................. ............. .I . iSeptic Tank (Specify Requirementsl ........ ............'.*............... ... ............................................................... ....,........_................. yr Disposal Field (Specify Requirements) ..........................:...... ........................................................----........................_....... F. .a......................................................................... .............................r...-,..............................r............................ ............................... !! ......................................................................................................................................................................................................... 4 (Draw existing and required addition on reverse side) 1 I hereby certify that I haveprepared this application and thatithe work will ba done in accordance with San Joaquin t ivnty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Homs owner or Iicow sed agents signature certifies the following: _ "I certify that in the performance of the work far which this permit Is issued, 1 shall not employ any person in such manner ' as to become subject to Workman's Compensation laws'of California." Signed . Owner By ......... .� ............ . xitle ...... (I raier tha�now a r FOR DEPARTM JEW,,fflSIE LY APPLICATION ACCEPTED BY '� . . _......... DATE .. 0..2A ? .................... ............. ........... ....•• ....... . .. BUILDING PERMIT ISSUED ...................-•-••-...... -- ----- .........---------DATE ........................................... ADDITIONALCOMMENTS ............................................ ..........................__....---........--••----...-- ........................... �. ...........--------•--------------------------------------------------------------------,............................................................._........_.,...............I......_I......._ ..................................I.........I............... 4 �. .. ....... ................................................... . Final inspection by '' eP ?!- ..:................................................................Date . ..-..f. . .......... 1H 13 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M