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FOR UFFICE USE: I l �PLaCAT30iq F0;! SANiTATION VERn ........................................ "Cosrplete in Triplicate) Permit .Jo �.::................ . / 'This trate issued _,�.�..1.".::'�-� '-------------------------------- -- - --------- / i his Permit Expires T Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install, the work herein: I � described This applicct�ona s made in compliance with County Ordinance No. 549 and existing Rulles nd Reg (at `ons: 49 JOB ADDRESS/LOCATION -- A , >--."` - --- e '- ��',/JJCENSUS TRIC y Owner's Name = ✓ Contractor's Phone ------------------ ----------------- ------------- _C Name -- ---- ----------------------- ----- ---- ----- --- --------------------- ----------License P Phone ` Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court '.❑ Motel ❑ Other ------------------------------ ------------- Number of living units:_.-'----. Number of bedrooms &------Garbage Grinder 'r ___ Lot Size -------------------------------------------- ! ' Water Supply: Public System and name --------------------------------------------- --------------------------------- ------------------------------Private ❑ Character of soil to a depth of 3 feet: Hard Hardpan E] Adobe FillatPeal --------- __ SandyeSLo}mX Clay Loom ❑ I Sand' Silt Clay .� 4 - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) o. NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) [n1 PACKAGE TREATMENT [ ] SEPTIC TANK Size__.f _ �. �. _ . " ..--- ----- Liquid Depth Capacity/..�-'_ 1(6----- Type 01 Material_ t No. Compartments ----------------------- _fDistance to nearest: Wel -..__--_� ------------------Founddtion -_ ! ----------- Prop. Line __ i _ -__---_-- LEACHING LINE No. of Lines - Len th of each line.- - -.-_---- Total Lengt�h ---------- LEACHING g D' Box `. .._ Type Filter Material f _z"I'-Depth Filter Material r,' /P/r __- __ __ k ---------------- Distance to nearest: Well __,6;q ---------- Foundation _. - ------------ Property Line -` _` SEEPAGE PIT Depth _..___._ ._.._____ Rock Filled Yes No ., _____ Diameter _, ��.___ Number _.._._ CC] , r c - Water Table Depth --_---- ------------------------------Rock Size --- - '7_-__-- ---- Distance to nearest: Well .___ --------------------Foundation -'-.�'��--_ Prop. Line .__ -_..________._ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------1 Septic Tank (Specify Requirements) ----------------------------------------- ---------------------------------------------------------- Disposal Field {Specify Requirements) -- - - -------- ---------- --- ----------------------------------------------------------------- F- ------------------------------------------------------------------------------------------------------------------------------- ------ ---------------------I—----------------------------------------- (Draw existing and required addition on reverse side) f 1---hereby certify that 1--h---a-v,-e prepared this applicati®n and that the work will be dame in accordance with S®ra J®squirt ' County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horace 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 subject to Workman's Compensation laws of California." FiSigned ------- �-- - - Owner BYi " - -- ----- ------------------------ Title � :. � �" --- -- -- ----------- .' I other than owner r F+I� FOR DEPARTMENT US ONLY APPLICATION ACCEPTED BY ---- �:� ' DATE ------ -- BUILDING PERMIT ISSUED - - -- ----------- - -- --- -- ---------------- F ---------------! ADDITIONAL COMMENTS - - , ---- - -- --- -- --- ----- - ------ ----------- --------- ......_...---- ..... ...... ------ --- ---.. --- - --------------- ---- ---- --- --- - -- ------ --------'----- -------------------------- - --------------...- --------------...--------------------------------- - - -- ---------- -------------- --------------- ------------------- . ---- --- ---- -- ...... ..... --..... ._._....-- --.--.._....- -- ._ ..----- --------------------------I....... linaf Inspection y ------------------------------------- - ...- ---- - - - --------- SAIN .OA(;, UIN LOCAL 1 E_,-%_TH 'DISTRICT