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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. .--Q_�� ----------------- -------------------------------------- gam. (Complete in Triplicate) Date issued ------- - ^4------ -=-- --- ------ - ------- ---------------------- ------- ---------- This Permit Expires 1 Year From Date Issued Application issheereb Lamade is°madeSon in compliance eLocal wi h County District Ordinance for No 549 and existing RuEesinstall nd Regulations- -------------- egulation herein J described. T pp 1 JOB ADDRESS/LOCATION .__ _____.___ -.-_CENSUS TRACT ___ ----- --------------- p, --- Phone - Owner's Name -1-_ Address --------�J O / G�cJ city -------------------- Contractor's Name --------- -- - ___.License #1-'W. ------ Phone Installation will serve: Residence XApa rtm ent House-[] Commercial [-]Trailer Court i❑ f Motel ❑Other ------------------------------ ------------- Number of living units:____f_____" Number of bedrooms "_C;?,,-"-Garbo Grinder --------- -- Lot Size _______-_-____-- ------------------------- Water Supply: Public System and name ____ "` -' "K"" ------Private E] ' Character of soil to a depth of 3 feet: Sand'El Silt C3 Clay El Peat EJ Sandy Loam ❑ Clay Loam I] H rdpan ❑t Adobe, Fill Material ------------ If yes,type -------l___--.____-___---- ++ � k T (Plot plan, showing size of lot, location of,system, in relation't w�]Is{#, bu Iding *�t be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted' if public sewer is available'wi i} 200 feet,) O PACKAGE TREATMENT [ I SEPTIC TANK:[ ] Size- l ",______-____ I------ 1_tqui Depth --------------------------V V ---- atedal------ --- No. Compartments ---------•-------: € Capacity -- -�--- ------ Type..----- --- � ` Distance to nearest: Well _ - ----1!--- ----------Foundation ___--"'"'--- --------�- Prop. Line -___-_--------------- �"" i, No. of Lines -- -- Length• f each line -Total"tLeng#h LEACHING LINE [ ] - l °� ,pNN T.. .a D' Box -------- --- Type Falter Material --------------------Dept F�Iter Material -"�------ k ,--� Pro # Distance to nearest: Well`' _-___^*;__----...F_oundat.ion. _----------------------- perty Line ____._______.-------- Distance - SEEPAGE PIT [ ] Depth ------- Diameter 1--t_ Number --------------------------- Rockl Filled Yes ❑ No 0 Water Table Depth ------- ---_--Rock Size -------------- -------- - ---------------------------------- ee � I Foundation ----------- -------E Prop. Line ------- -------------- Distance to nearest: Wel! ______________________________________ _ REPAIR/ADDITION(Prev..Sanitation Permit# ------------------------ --------------- Dater ---------------•' -1 Septic Tank (Specify Requirements) ----------- ---- - -------- E Disposal Field (Specify Requirements) ___- " --- ------ --------- ------------------------ -—--- k , - Q---- -- {Draw existing and required addition on erre side) I hereby certify that I have prepared,this application and that the work will be done f,m,_,accordance with San Joaquin County Ordinances, State Laws, and ;Rules and Regulations of the San Joaquin (Local Health District. Home owner or licen- sed agents signature certifies the following:___ _ ) d e,w _+- . "I Certify that in the performance of the work for which this permit'is issued, T shall not employ any person in suchmanner as to become subject to Workman's Compensation laws of California." Signed ". " .4'�" nef -------- l� Title -- ----------------- -- ------------------- ---- - - ---------- -- (If other t owner) FOR DEPARTMENT USE ONLY --------------- --------. DATE _3' 'JU------------------- APPLICATION ACCEPTED BY�--�'""-- - -- ------------- ----------- ---------- -- BUILDING PERMIT ISSUED ----------------- ------DATE --=----------------------------------------- ADDITIONAL COMMENTS ------------------------ ------------------------------ 4 ___________________________________________________ _____________________________ C, Final Inspection b /" ------- ----------- Date - ----- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M