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a .......................... APPLICATION FOR SANITATION PERMITT ..................................................... lCot"Pleft In Triplicate) Permit No. ............................................ ............. This Permit Ex IreI Year From bate Issued Do!* fasued Application Is hereby made to the SonJoaquin Local Health District for a permit to c described. This application Is made in compliance with countnstruct and Install the work herein County Ordinance Na.N549 and existing Rules and Regulations: J013 ADDRESSAOCATION Owner's Name fi .................................CENSUS TRACT ......................... .............. Address ............................. ............................. ......Phone ........ ........... .......... ..............-City Contractor's Name ....... ...............I............................... . --------*.....................*......*------*License# Phone Installation will serve, Residence WrApartment House 0 Commercial C)Traller Court 0 Motel r-1 Other Number of living units............. Number of bedrooms ............Garbage Grinder ............ Lot size -.................. Water Supply; Public System.and name Character of soil to a depth of 3 feet: Private ❑ Sand E3 Silt Ej Clay [3 peat0 Sandy Loom Cj Cl Loom 0 Hardpan Adobe C) Fill Materia! ............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 Public sewer is available within 200 feet,) PACKAGE TPEATMENT I I SEPTIC TANK Size................................... Capacity .................... Type .................. Material. Liquid Depth ..... .................... ..- No. Compartments .................... Distance to nearest. Well ....................................Foundation ...................... prop. Line ..............;...... LEACHING LINE No. of Lines ....................... Length of each line..... ....................... Total Length lwvlge.M:� V Box ............ Type Filter Material lc�pe.....Depth Filter Material Art." • Distance to nearest: Well ..........I.............. Foundation ........... SEEPAGE Property Line ....... PIT Depth .................... Diameter ........... ................ I Water Table Depth ..... Number ............................ Rock F1116d Yes No ............................................. 40 ._......Rock Size Distance to nearest, Well ...... REPAIR/ADDITION(prev. Sanitation Permit 0 .......... .....................................Foundation .................... Prop. Line .................... a . ....................... Date ................................... Septic Tank {Specify Requirements) .......................... Disposal Field (Specify Requirements) ......... ........... .................................................... ........... ... ....................... . .. ........................................................................ ... ......... ........................................ ............ .......I............................I.............................. ........ ..........................I.................. ........................................... .......................... ........I............... ................................................. ..................... ......................................................................... (Draw existing and required addition on reverse side) I hereby certify that I have Prepared this application and that the work will be done In accordance with San joaqu County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Ho sod agents signature certifies the following: me owner or llc*np "I certify that in the performance of the work for which this permit Is Issued, I $hall not employ any person In such manne as to become subject / .511 -P-Workma Compensation laws of California.- Signed ...... ......... .. Owner By ................................... (If other thaW'owner... ...*.................................... ................ Title ....... ........................... ) ............... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By ...... BUILDING PERMIT ISSUED ..................... ............................................. DATE ADDITIONAL COMMENTS ..........................*------*..........*.......*---------------- .DATE .... ..................... ............................................. ..................... ......I.................1.................... ......... ......... ....... ............... ...........I...................... ................I......................I.......11.............. .......... ................... ..................... ................... ................. ........... -1.................. .. ....................... . ..........I..................1.11................ ......... ........I.............. ............... Final Inspection by: ...................6�-e........................I.................................. .L......................... ..... /. . . ........... EH13 24 1-6[1 Moa. ....................*.........*----------*......*...............................--•-----.................Date ... 9`1 SAN JOAQUIN I.OcAt HEALTH DISTRICT . ................ 8/711 3H