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` FOR OFFICE USE: a.�IPPLICATION FOR SANITATION PEAT ,; 6 6 f 04; tt Na. ....(Complete In Triplicate) .. . .. . /1 - issued .. ............. ..................................................... This Perini(i:xpires 1 Year krant Date issued Application is hereby made b the San Joaquin Local Health District for a permit to construct and InPond a work herein described. This application is made in compliance with Count Ordinan No. 549 and existing Rul Regulationsc /� �'7 n CENSUS TRACT .................: JOB ADDRESS/LOCATION ../-O.7--..,1-.�r ..... . .. Owner's Name .. -�.. ....... ...................................................Phone .. - Address ' • ....,..:City _ ------. -- --------------- ---- . ... Contractor's Name .......................License • Phone . -.._.. ,C.. . Commercial ailer Court Installation will serve: Residence Apart ouse fl m ]Tt Motel Other...... ......................................... Number of living units:.... Number of bedrooms . Garbage Grinder ............ Lot Size ._ ... ...... Water Supply: Public System and name -----•--•--•-----•---•-•---------------••••............._..............................._................----PKivate Q Character of soil to a depth of 3 feet: Sand b Silt❑ Gay ❑ Peat Sondy koa • Clay Loam Hardpan❑ Adobe❑ Fill M6terlal ........... If yes,typo............... .. ...... (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is availabia within 200 feet,) i = PACKAGE TREATMENT SEPTIC TANK I } .......•.... Liquid Depth ... ...........•--•--. Capacity T ......... material--�' No. Compartments "�. ., Distance to nearest: Well ..............Foundation ..... prop, Line .+ .��.... LEACHING LINE I No. of Lines Length of each line...... ---.a.......... Total Length .......`_,�.�z.......-. 'D' Box I........ Type .Filter Material -•t•_, r---Depth filter Material ...Z.1r.............................. Distance to nearest: Well ........................ Foundation ---•--.-•- ............. Property Line ........................ •--SEEPAGEPIT Depth..A./_OAIr Diameter ................ Number ........�,,� ........ Rock filled Yes No 0 r� Water Table Depth •....................•--••---............ .Rock Size ............:_..,............... Distance to nearest: Well ----------------------------------------Foundation .................... Prop. Line ....•............... REPAIR/ADDITION(Prev. Sanitation permit# ___......................................... Date ._-................................I SepticTank (Specify Requirements) _----------- .............-•.................-............................................................................................ Disposal Field (Specify Requirements) --• ..........................................................-......................................................... ................................_.......-----------------------------•-•--------------------••---•------------..-...-•----•------••---------..-.........---...------•................._........._-_.... (Draw existing and required addition on reverse side) I hereby certify that i have prepared this application and that the work milli be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,DIstrict. Rome owner or Iitett• 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 Work m on'lSompensation laws of California." Signed . ------ - --- - 4/n / Owner t ------------------ Title - ----- BY - ------ ----- -- L lof r th owner) FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- - -- ------ ...__:._ � _ .... DATE ..... ..... ... .......... BUILDING PERMIT ISSUED --.. ........... ..............DATE ........................................... ADDITIONAL COMMENTS ---_.................... ........................................ ..---------I............... ........... -------------------------------- .--1_._.._...---•----.....--------......... ................... .................................. ........ -..... ---•...... ............... .......................... . .. ----- Final Inspection b ..................................... --_....Date ..f..f / . EH 13 2! 1-68 lbay. 5M SAN .lOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M