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ij FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7G /c�7 s x ..................... Permit No. ...... .......... (Complete in Triplicate) .:,'. ....................... J .�L Daft Issued ................ ............ ............................................ This PenrtH Expires/ Year hent Date Issued ;.r Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install fM work herein ' described. This application is made in compliance with County Ordinance No. 5d9 and existing Rules and Regu[~1k ... JOB ADDRESS/LOC ONCP5P.-9G1/ ... ...... . .... .CENSUS TRACT y�3 Owner's Name .. ... ...:................. .......................... one Ph n Address . . ,0� l0. ..... . . 4.... . ............City .��.... /... .. . '} ' - t_�f`a,��i..s ,l..................Lidnse ��.'.S�L�-'... Phone ....... . .. ;- Contractor's Name .. �`'0, .... ...... ='. Installation will serve: Residence[Apartment House0 Commercial ❑Trailer Court a Motel❑Other.....-?.7...............�................ Number of living units:....�..:... Number of bedrooms ••••• Garbage Grinder ..... ...... Lot Six* w Private Water Supply: Public System and name ........................................................_.................. ; Character of soil to a depth of 3 feet: Sand J Slit❑ Clay ❑ Peat[3 Sandy Loam day loony❑ • Hardpan❑ Adobe❑ Fill Mctorlol ............ If yes,type...... Y (Plot plan, showing size of lot, location of system in relatione•) to wells, buildings, etc. must be placed on r*vw" skl permitted If public sewer Is available within 200 feW NEW INSTALLATION: (No septic tank or seepage pit pe p PACKAGE TREATMENT [ ) SEPTIC TANK{ ] Size............................... ..... ....... Liquid Depth ......:.:.. ty ..... ....... .. .. Material............ No. Compartments ......•••••U Capacity . Type f 4 Distance to nearest: Well ...........Foundation ..... .. . .......... Prop, line Total Length No. of Lines Length of each line..................... . . .. g " • LEACHING LINE [ J •••••• � � , E � 'D' Box ... .. Type Filter Material ....................Depth Filter Material .... t ........ Foundation Property Line Distance to nearest: Well ....:........... - r SEEPAGE PIT Depth Diameter Number .......... Rock Filled Yes C❑ t'b Water Table Depth Rock Size ........................ : ......... .... ................................. K Foundation Prop. Line ..... . . Distance to nearest: Well ....................................... f ................ Yc REPAIR/ADDITION(Prev. Sanitation Permit vlt -.......... ................................ Date .................. 1 Septic Tank (Specify Requirements) ..................................................................../.............................. Disposal Field (Specify Requirements) .... - � [ ... ..................... ............ .. .... .. .... ....... . ............... . ........................._........................ .. .................... ,. (Draw existing and required addition on reverse side) �2? I herby certify that 7 have prepared this application and that the work will be done in accordance with fan rJeale County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin local Health DlsMct. Hence etyrter N (tan sed agents signature certifies the following: "I certify that in the performonce of the work for which this permit is issued, 1 shall not employ any penes IR such trtaRRr as to become subject to Workman's Compensation lows of California." Signed I Owner Title .."'.4 By .... �1.�..C%K .�.tr................... . ... ..... .. (If other than owner) ,x R DE ARTMENT USE ONLY DATE .......... . .. . . . ................... .............. APPLICATION ACCEPTED BY ............... x BUILDING PERMIT ISSUED ... ... DATE ...... . ...... ......... .. ...... .... . s:a ADDITIONAL COMMENTS ................... .............................................._........................ .......... ..... ......... ... ... .................. ..... .......... .. .. ................ :........ ....... .. . .-...............:...........• ................ a �� ... Final Inspection b �� - .... . ......................... . . '' EN 13 2L 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M