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APPLICATION FOR SANITATION PERMIT � ....................................................... (Complete In Tripllcahl Permit No.26.:`. ... ................................ This Permit Expires ! Year From Data Issued Date issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application Is made In compliance with County Ordinance No. 544 and existing Rules and Reputations: .JOB ADDRESS/LOCATION .. ��i .�.. ... ...................................................CENSUS TRACT .......................... Owner's Name .. :i, a !. �,.,[�.,. e.. �.�.... }�. f................................................. . ..Phone . L�l. .Q��t�. Address ...............7-.��.1. ...Yid.. 2 4�....�[ ..... - .......Ci 5r `._ .......... �j ty n1 ........................ Contractor's Name ................ . s--.. ... r'?.cam ._.__...__.......license r..�.L:-r� ..... Phone �? .:_ �fl.�........ Installation will serve: Residence Apartment HouseQ Commercial[]Trailer Court 0 Motel❑Other..� —f - ---..•------- Number of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Size ................... Water Supply, Public System and name ...................................--------------------.....-.................................................Private Character of sail to a depth of 3 feet: Sand[7 Silt❑ Clay Q Peat❑ Sandy Loam ❑ day Loam Q Hardpan❑ Adobe M Fill Material ............If yes,type............... ............ (Plot plan, showing size of lot, location of system In relation to wells, buildings,.*tc. must be placed on reverse side.) NE411 M STAID TION: IN* septic tank or yse�e �j a�jJ(fllt rym,��i/�t)ted if public sewer is available within 200 feat,) }�, "V 1, JI f ry PACKAGE TREATMENT [ � SEPTIC TANK "- IlZ �1 ze....... .....�. ..��.................. liquid Depth .... ........... Capacity .45.O ......... Type Material__ ,r..... No. Compartments ....... :. ....._ r Distance to nearest: Well 4D 'r ! .-:f:.... Prop. Line ' -�' ....................................Foundation . ...----� r p ....... ........... LEACHING LINE No. of Lines ........r............. Length of each line.... -..6__10..._.,..... Total Length . _ 6................. 'D' Box ....! .. Type Filter Material 1 ..... Depth Filter Material ......../1 ._f.......................... • r Distance to nearesh Well ......�Q.{'......_ foundation ..... +-...._. Property Line .. .t............ _ Depth .....�5_r..... Diameter _._!�`.... Number ... _ - Rock Filled Yes'o No Q SEEPAGE: PIT `[`� ....... ---•- --••--- Water Table Depth _.....---•-----•................................Rock Size _5�.`'.1 i.ZZ ....... .: ► Distance to nearestr Well ........... ._.:?.............Foundation ._./_0... ..... Prop. line -• ------ ---- REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date .................................. Septic Tank {Specify Requirementsy ...................................... ...............................................................:..............._................ DisposalField (Specify Requirements) ...................................................................................................................................... - ... . ..............•-.... ................... ......._............ .........,........-..............._..........._........._......... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this applicallon and that the work will be dere In accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen- sed agents signature certifies the fallowing: "I certify that In the performance 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 . title �.................. By ..................( I.._..... ..f..... . -1 . ..... ........... ' ,.._........._. ......_....................- If oche an owner FOR DEPARTMENT MSje 4 Y APPLICATION ACCEPTED BY .... .. L � DATE .... -e� - :.. _... ................... BUILDING PERMIT ISSUED ............. ....... ....... . ........--------•---- . DATE .. ADDITIONAL COMMENTS ............. . .� :. i :............. .. ...-f�l.�..�.....J.n-� �- .---•..................... ............................................. Final inspection by: ................�.. .... .... . _... ....------.............----._,.........................................Date -- .-.-.-.......... FH 13 24 1-60 Rov. � 5AN JO AQUIN LOCAL HEALTH DISTRICT �?�t �