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l:oR OFFICE USE: 75 ��S'• r` APPLICATION FOR SANITATION PERMIT ... �--- .............. �! (Clete a in Triplicate# Permit No: . .. . ...II ......................: . ... .. This Permit Expires 1 Year From Date Isaued� . Date Issued Applkation is hereby made to the San Joaquin Coca( 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: CE J . SOB ADDRIrSS/LOCATiQN.......70o... :..,f.',....... . . . ....... :..... ..:.....:4.....:.....................:. N511S TRACT .......................... Ow:ner's Name .. .. . ...... G�!(�.. .............:..:.....................Phone ......I......................,.. Address . �C. 1. ..........:... .. ._ . ...City ... ._._... Cori#ractor's Noma ...... --••:..............License J'3 .&. Phone I� . . Installation will serve: Residenco EX Apartment House C3 Commercial 13Trailer(:surf ! 'Motel 0 Other............................................ Number of living ullits�_:..Jl...... Number of bedrooms -::....Garbage Grinder Leat Size , Water Supply: Public System and name ....>........ . ...............:.: .._..._..:...... ... .. :.........:......Private ` ` w'Character of sail to a depth of 3 foot: Sand[] Silt❑ ..,.Clay Heat[ ' Sandy Loam 0. Clay Loam Q I ' Hardpan❑ Adobe 0 Fill Mafetial ............if yes,typo............ .. ............ : {Plot plan, showing size of 'lot, location of system in relation to wells; buildings, etc. must be placed an ravers* skle.l NEW INSTALLAT#ONs (No septic tank or seepage pit permitted if public sewer is available within 2017 feet,; { PACKAGE-TREATMENT .I ] SEPTIC TANK .....X.X.��:. .::. . Liquid Depth .... Capacity .�:: .(�.. Type •--�-_. Mt+erial.. ';y ...... No. Camparltrrenb ..:�., .... ,.. Distance.to nearest: Well _. ... ..... .........Foundation ........................ Prop. Lina .................. �I i LEACHING LINE [ ). No. of Unes ....... .... ... Length of each line......... ...0 . ... .. Total Length ..� ........ 5 v Box . Type i"i#fsr Material .... :...Depth Filter Material .. ... j Distance to nearest; Well ........................ Foundation ... ...........-._--. Property Um ..... j ......... SEEPAGE PIT ( j Depth .................... Diameter .:........:..... Number ............... Rock Filled Yes No Water Table Depth ...... ..................................... .;tack Size .. " ................ . Distonoa to nearest: Well ... ........................:...Foundation ..... ........ Prop. Line ............. . . 3 REPAIR/ADDITION#Prey. Sanitation Permit# ................................. Data --� , i ..... Septic Tank (Specify Requirements) ...... .................................... ................................................................... ....._.....-................. Disposal Field (Specify Requirements) --•....................................... . .._.....:--- . ........ ....... ............... {7I _.Ea. �......... ..................... -y' ............................ ........ .... ............ _ ......... .......,_......_........ .::................. 1 +. . {Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that Pse work wI1 be done in accordance with San . taunty Ordinances, Stat® Laws; and Perles and Regulations of the Son Joaquin Local Health.District. Hants owstar a' ilsen- 1 "sed agents signature certifies the following: . N certify that In the performance of the work for which this permit k issued, I shaill not onploy any pars" In such manner � as to becomes bje Wor man's Com ensation Laws of li#ornta," li Signed --- . •. . --- ... Owner . i ................ Title _..._... ------ .... _. (if other than owner] . _ji FORt DEPA TMENT USE ONLY APPLICATION ACCEPTED BY . DATE.._.,.��.:. _�' ..._..:...: BUILDINGPERMIT ISSUED ........-- - - ----------------•....--•---.---__-_..__.......-----...---..__....•--..._..........._.DATE ..... ............................ ADDITIONALCOMMENTS .............. ; .....__.......-------------....................................... ......................... ................... •--.---.....--•--..............................--•................................... ..............•..................... .....__.. _ .._.. ....._.__ : ......_. _ ... ............. . ........ _. Final Inspection by: .._.:._.. ... - -• • ............. .......................:............ Ell 13 2h1-6f# 2tc SAN JOAQUIN LOCAL' HEARTH DISTRICT 8/7h 3M ' E� .