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FOR OFFICE US APPLICATION FOR SANITATION PERMIT �� 36 3 ....... (Complete In Triplicate) Permit No. .............. Date-liw6d`- .'� ....o_.._�.., ....................................... .. ...... This Permit Explres 9 Year From Date Issued Application is hereby made.to the San Joaquin local Health D15trict for a permit to construct and install the work heroin described. This application Is made In compliance with County Ordinance No. 549 and existing Rules and Regulationse ® ....................................................CENSUS TRACT .......................... .DOB ADDRESS/LOCATIO V/0. ... ... ok-Ar- Owner's Name ....................................... ,. ............. .....P.....Phone ..........:................ .. Address ............ cz� O d j'1. .City ... . !C!. ...................................................... ►ay Phone Contractor's Name ... ..............license #�� . :... . f + Installation will serve: Residence❑Apartment House 0 Commercial{]Troller Court ❑ 4 i Motel❑Other Number of living units:_..'_..L... Number of bedrooms --.>--- Garbage"Grinder ............. lot Size ..�s..................... . .....:...... ` Water Supplys Public System and name .............. ...Private E� Character of soil to a depth of 3 feet: Sand❑ Silt E) '.Clay ❑ Peal:❑ Sandy Loam Clay loam ❑ F. > Hardpan❑ Adobe❑ Fill Materlal ............ If yes,type........................••. (Plot plan, showing size 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 r blic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK(LK Size ....l.�.... ----....... Liquid Depth ....Zr................. Capacity 1 T e (�- Materlal... No. Compartments ................. Distance to Hoare t: Well .- .Foundation 1 .:......... Prop. Line t /----•----.... nth of each line.....__ Total Length ..- �P. .. .......p LEACHING LINE [1 No. of Lines Leg .. 'D' Box Type Filter Material — ...Depth Filter Material ------1.4.......................... df Distance to nearest: Well .. 4?......... Foundation ......./W..l......... Property Llna.,=• ' Depth ---.-..1.Q. Q aaa#er Number ..-•....: ........:. . Rock-Filled Yee gNo ❑% Water Table Depth & ..... ...........Rock Size ...J. ....... I Distance to nearest: Well ......46;:;;4_A.................Foundation _.,f ... Prop.. Line ...... =...... f ---....-- - --•- lihPA1R/A1�biTIQN(Prev.Prey. Sanitation Permit� .....--.•--••--•----••••-•--•-------------- Date ........................I Septic Tank (Specify Requirements) ....................... ... ... . . ..... .. ......................... .. ._.................. ... .......in' Disposal Field (Specify Requirements) ...............................................:.......... .................................:.............. ...................... , .... -----•.........•---•...........••...• ...-••-•-•....................................... .... Y .....•. .................. ......................................-......................... ....... sS ...•......•... ..._-•__. ..... (Draw existing and required addition on reverse side) I hereby certify that 1 have,prepared this application.and. that the work will be done In accordance with San, Joagrrlo County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Iicen- sed agents signature certifies the following: "I certify that In the perfarrtmance of the work for which this.permit is issued. I shall not employ,any person In such manner as to become subject to Workman's Compensation laws of California." � . Signed ....................... ... --•-•- ---. .... .. Owner k By .............. :............. .. .. .... ... .. ...._.. .- -- --_. Title (If other than owner) 4 FOR DEPARTMENT USE ONLY _$7 APPLICATION .ACCEPTED BY . �s .... -------•.........................................DATE....... ::,:.__ . ..,..,;.- BUILDING PERMIT ISSUED ..................... .......DATE ...-.........................._.... ....... ADDITIONAL COMMENTS ............ ...... ... •-•...................... ......................................................................... .. Date .. i .................. ---• � �� Final inspection by: -- 't. ............... .. EH 13 24 3-611 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT S/?!t 3M