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FOR OFFICE USEs APPLICATION FOR SANITATION PERMIT ..................................................I...... (Complete in Triplicate) No. ... ................. ................................................. This Permit Expires 4 Year From Date Issued Date tssuad .'7`' f Application is hereby made to the San Joaquin Local Health District 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 Regulatlonss JOB ADDRESSAOCATION .. .... .�� ..,t� .. -r. .(.'..CENSUS TRACT ........................... —, Owners Name ........... i' V/or...........................................................................Phase .� .......7,��. Address ................... ................... We...........................................City ............................................................................ Contractor's Name .....................................0 ............................License #t ........................ Phone ............................. Installation will serves Residence❑Apartment House❑ Commercial❑Trallw Court P Motel❑Other............................................ Number of living unitss.....I Number of bedroom: 1-Garbage Grinder Lot Size .... .:......... Water Supply, Public System and name ......................................................—................................................... PrhraM Character of soil to a depth of 3 feets Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam❑ Clay Loam Hardpan❑ Adobe❑ Fill Material ............ If yes,type............... ............ Mot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATIONr (No septic tank or seepage pit permitted if public sewer Is av rlabl [thin 300 feet,) PACKAGE TREATMENT ( } SEPTIC T/ANNK{ Size... !L` ..�C ... . Liquid Depth Capacity A Type 1.r>r_JWi Material.�i� No. Compartments ..z•••..........0 ' Distance to nearest: Well ........_. � ............Foundation ... Prop. Line. ......0 LEACHING LINE No. of Lines ...........I. .. ... Length of each line........., ......... Total tan th ...... ......0 -D. Box ... ... Type filter llAaterial f E. epth Filter Material ...._. .. ., 1. ..... t; Distance to nearest, Well ..... ..... Foundat on .....(1/��:...... Property Line ..... •••••••m SEEPAGE AIT O Depth Diameter I .......... Rock Filled Yes ❑ No .................... ................ Number .................. , Water Table Depth ................................................Rock Size ................................ ° Distance to nearest, Well ........................................Foundation .................... Prop. line ..................... . REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ................................ .I Septic Tank ISpecify Requirements) ................ ................ ................................... ........... J- ................,......J Disposal Fleid ISpecify Requirement ..... •••••••• 01 op r ,�.� .........:.................................... iDexisting and required addition on reverse side) 1 hereby certify that 1 have prepared this application and that the work will be done in accordance wllh !fan Jeaqul;. 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: "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 subi ct te Workman's Cz .......... ....................... sation laws of California." Signed ........ ..--�� Owner ........ Title Ilf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ......:.........._ ..... DATE ..../ P?.fir.:..........: ............................................................................ BUILDING PERMIT ISSUED ..........DATE .: ......................._............... ADDITIONAL COMMENTS ...... ............. .................................................. .y ........................ ......................................................................................... ...... ........................................... ....... ..... ...................... •.................. ....... ..:... ...... .---. .... .................- .Date ...x.17: 7. ,ter Final inspection by. ...................:...�T �---•-....................................................�..... ....:------.- EH 13 24 1-69 Rev. 5M SAN JOAQUIN LOCAL HEALTH :DISTRICT 8/7b 3M