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FOR OFFICE USE: ...... J, APPLICATION FCR SANITATION PERMIT i IComplete in Triplicate) Permit No.%'�-- . .. ......•............... This Permh Expires t Year From Dote Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Reguhu ork herein JOB ADDRESS/LOCATION .- r .. C Owner's Name . ' ..� .-}... ..... moo"Address ✓ : . �✓.. ,�....... .✓< .................. City Contractor's Name _�... '� �,� '•' • •-' : --�� c�.L /. :. .:>t_ ...License # �,1 f %,<' phone ' Installation will serve: Residence portmont House 0 Commercial ❑Traitor Court 0 Motel 0 Other.. .................. Number of living units:.._..... Number of bedrooms .-H Garbage.--- �g Grinder ............ lot Size WaterSupply. ....................................... Y: Public System and name ..............•.........................................._.. .Private pp [ - . . Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ pear 1:1 Sandy Loom 0 Clay Loam Q Hardpan❑ Adobe❑ Fill Materlol ............ 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 feat,} PACKAGE TREATMENT [ ] SEPTIC TAMC £ ] size................................................ Liquid Depth .......................... Capacity --- ------ Type ..... .............. Material...................... No. Compartments Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE [ j No. of Lines ........................ Length of each line............_........._..... Total Length 'D' Box ..---. ----- Type Filter Material ....................Depth Filter Material ................... Distance to nearest: Well ........................ Foundation .. Property party Llno .................. O SEEPAGE PIT ( 1 Depth ---------- -------- Diameter Number -------- ............... Rock Filled Yes No . . Water Table Depth .............. ❑ ............................Rock Size ....----...------•.... Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------................... Date .................................. Septic Tank (Specify Requirements) . ... Disposal Field S if Re virements � �`� .._ ........_... .. ...................... l � Y ' C...... ``.._. --- ....................... - -_ •_•_• ....._. ...................... Draw existing and required addition . - ds.I •-------•-•---•••---•-••..................................•. 3 on reverse side) 1 herby certify that I have prepared this application and that the work wiH be done M accordance with San .loagrrin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local NeaNh Distdo. Name or Itcen- owner �1 sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is Issued, 1 shell nae ernploy any person in such manner . as to become subject to Workman's Compensation laws of California.•' Signed ... ... _ .. ._. _ 1- ----•----•-•-••---•---•--- Owner I _�c<.: Title ....� r ( f of er than owner DEPARTMENT USE ONLY APPLICATION ACCEPTED BY T BUILDING PERMIT ISSUED --- ------- -- - --•-------'- -- --- --- DATE 11�A��-.7.5- -.._.: ------------•-----. ... ... ----••............ .... .........DATE .._._. ADDITIONAL COMMENTS ----- ------------ ---- .._._.._-- ----......._ .._.... . ..................... .-- ......... Final Inspection by: . EH 1,3.211 1-68 Rev. 5�i ....Date .. ." 4�..? SAN JOAQUIN LOCAL HEALTH STRICT 8/7b 3M