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FOR OFFIC Usl - APPLICATION FOR'SANITATION PERMIT a ------- rm . .... )Complete lri Triplicate) _... tNoA e ........................ x ss t• ued . ... ............... .........._..:.:. This Permit Explres 1`Year From Doh Issued nate ( a/• 7 Application`is hereby made to the Son Joaquin Local Health District for a permit to construct and Inst Rohe work herein described. This application is made in tom" )lance with County Ordinance No. 549 and.existing Rules and Regulations: ;. ...............CENSUS TRACT VI.OrATION ........._..... -. . :.. .. - .. _ .._..... G l�........... JOB ADDRIES ' .r .......... ....:. . Phon f�. , ...: . Owner's Name i..•C-�.... �';... 1.. . . r7 Address ms s.- ..... .G�l C [ ': .......... city ........ ........... Co ntractor's:Name license # Phone # . ........ .. ............................ lnstallation�will server;"` Residence [ Apartment Houseo Commercial []Trailer Court Motel ❑Other ............................................. Watere` of�liv�n� units_CJ)►�:. Number of bedro ms Garbage Grinder d... Lot Slze, .-.......................................... Suppiy..'Publie'Systern.and name :._ t ,. .. ---- ...._................... .............Private ❑ i Character•of soil to a depth•of 3 feet: Sand E] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam Ef Hardpan E], Adobe- Fill Material ..........,.- If yes,type V' F IPlot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed an reverse side.) NEW INSTALLATION: (No septic tank or seepage pit,permitted if public sewer.is available within 200 feet,} C T ----... Liquid Depth ........�..... PACKAGE TREATMENT _f. ] SEPTIC TANK��r`5 l z••�'--••................... opacity U--- Type -------------------- Material.. o. Compartments ...2 ........ i Distance to nearest: Well ........ ..................... ion .....--•.............. Prop. Line ..................... . Foundation LEACHING LINE `-I f&.. df Line -.---� ---- ... -- Length of each line .._`. :.:....:.......... Total Length .........--................ � ler-Materlol ............D' Box .._.. Type Fit .......Depth Filter Material � Distance to nearest: Well ...., ......... Foundation ........................ Property Line -.-.................... SEEPAGE PIT [ .] Depth .................... Number ............................ Rock Filled Yes ❑ No Q Water Table Depth Size ................................ Distance to nearest: Well --- _---------------------_ ............Foundation -- --- ........... Prop. Line .....................- !'AtEPAIR/ADDITIQN�(Prev. Sanitation Permit# • Date Septic Tank (Specify Requirements) ---------------•--------------.--....' ............ Disposal Field ISpecif Re uirements} --•-- .�.:: ::_--.__.---•-- •a� �........ ......... ...__ 4 -. G I DrG existing and required addition on reverse side) I .hereby cea'tify lknt :l, ho prepared: this application and that.•the work will bo-done .in accordance with San Joaquin `County Ordinances`'0ate. Laws, and Rules and Regulations of the"S Joaquin Local Health District;Rome owner or licen- sed agents signature certifies the„following: , ”i certify that in the performance of the work for'vithich this permit is issued, I shall not employ any person in such manner as to beta a lett to Workman' ompensation laws of California." Signed ------- Owner .. - ................ By ....... .. .-----------•.-------.--------------------------------------------- 7 .. ... (if other than owner) ' FOR-DEPARTMENT<USE ONLY77 _ APPLICATION ACCEPTED BY• DATE BUILDING PERMIT ISSUED ....-----"" �` ` DATE ..... .. ADDITIONAL COMMENTS _... --------- .............. :. ............:. ... -. ..........................:.........:................-----_.___:_.._.. __..__.._. -._..-..___.___.-___-..-..__..._.------..---._. -------------------------------------- __._._.._____........_-.._...__._.___.._....._.._.._..__._.._...__..... ------ .... ..... - .._...._._.___.._.........__�_....._...........------- .... ..... _.. ...- Final Inspection by- .............. -- --------.-.-. -- - .........................Date .. .: ._. _.. ' EH 11 21 1-68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT t 8/7h 3M