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FOR OFF1C154iSE: v . APPLICATION ICOR SANITATION PERMIT {Complete In TitlPlI"!* rrrtNo. -- - Pe it �.. y � r a , This Permit Expires I Year From Date Issued. Date issued •---••--•--..._.._.. _ a Application is hereby made to the San Joaquin Local Health District for to -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: ' ' 52- JOB ADDRESS/LOCATiQN IS n Owner's Name .... .�. _...._._ .. - ............ CT .................... .. . ` ............................................. .-.......---Phone ................................ Address ---. ....... �...__ ........ ...., ciri ............................... Contractor's Name ... rz t. '...-:- `'-c�_._ ::............License s9` Jc� --... Phone - G Installation md1l serve: Residence❑'Apartment House Commercial❑Trailer Court ❑ i Motel ❑Other............. ......... Number of living units:..._Z.... 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 Q Clay ❑- Peat❑� Sandy LoamI i.�C ay Loam ❑ ; Hardpan p Adobe 0 Fill Material ............ 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,) r PACKAGE TREATMENT [ ] SEPTIC TANK[ Siie ................................. Liquid Depth k Capacity --•-••--------------- Type .............-... ... Material---................... :No. Compartments ..:................... Distance.to nearest: Well Prop. Line _...-.....Foundation LEACHING LINE` ] No. of Lines ...............:. Length of each line............................. Total Length .I %P 9 'D' Sox .... ------ Type Filter Material ....................Depth Filter Material ...................--_-...................... 1 - . .b i YDastance_to.nearest: Well Foundation ..-•--------•-• --- Property Line ........................ SEEPAGE PIT [ Depth .................... Diameter ................ Number ........__._._.._.. ........ Rock Filled' Yes ❑ No t] � I Water Table Depth ............. ---- Rock Size .- ................................ Distance to nearest:.Well -___'_......................................Foundation --.•_ Prop. Line .. } REPAIR ADDITION'(Prev. Sanitation-Permlt '.....--='= - _- _ _..._ .Date ...... i Septic Temic (Specify Requirements1 - -- .................... -._..... ............... ... ....... = - G ......--- Disposal Field (Specify Requirements( --G�-r� .- ..:, - •------ ------- •--• -- -- ---------------•- --•-•--._........_- ... - ------------ -. --- ' (Draw existing and-required addition on reverse side) I I 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 HoaI&DlstAct. Hance owner or Ilcen- sedagents signature certifies the following: r certify that.-in the-performance of the work for which this persnk is,issu_ed, 1 shall not employ any.person In such manner as to become subject to Workman's Compensation laws of California. Signed -- ------------- --------- 4 -------=-------------- - F Owner r BY ---------- ------------- -----------•----- -- .. Titfe _ ............... ---- ------Iif other.than:owner) i t ' " FQR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . --------- -------- ------------------- --------------.• :....:. .,DATE ._..: .__I ----•-:- BUILDINGPERMIT ISSUED -_--------------------------- -•---------------------------------------------------------------------DATE .............................................. ADDITIONAL COMMENTS ----- -------- -------•------------------------ -----------•------•------------------••-•----• ----------------------------------••------- --•---------.._...-..---- ---- ............. s --•-----------------•----•--•--•-------------------- --------------- .•....- Final Inspection b Date _....... _..."......................... 13 24 1--613 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M '