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• � rr � FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .... Permit No x. iComplete in Triplicate) b n .......... - - ....................... qq �i ................................... This Permit Expires 1 Year From Date Issued Dass Issued..:1. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install tM tivetic INfrtn'ti- described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Rogulationst JOB ADDRESS/LONCPo.3G/ ._. ` r r .. ....:... CENSUS TRACT� . v c Oca .... .... .....: _ Owner's Name Phone �c to Ci n .....: �r Address I ........... /Sc+i�. .................cit .. ? e t Contractor's Nome-.�;tix.+J.+✓..... .....��!.. ..,................Lkenss* f�.�� .,?�.. Ph tint ti 1,� instolla+ion will serve: Residence[5'Apartment House0 Commercial❑Trailer C cert ❑ - yt{ Motel❑Other: .................................... � . q Garbage Grinder lot Size Number of living units:. . Number of bedrooms Water Supply: Public System and Hama .................................................................. .......... Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Psot❑ Sondy Loam day Leam w � Hardpan❑ Adobe❑ Fill Moterlol ............ If yes,type ......: Q _ - t; (Plot-plop, showing size of lot, location of system in relation to wells, buildings, etc. must bi400e Aen-�i ° NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available withM'400,fNf,) y n : PACKAGE TREATMENT ( ]. ,SEPTIC TANK I. ] Size..............•.................... ... ...... Llqu(dZD�ept�h �x Q .� ......... .... N . Capacity ...::............... Type . Material........ o CompattntinM ..Foundation •'Prxx Distance to nearest: Well aP Ifni •""'•+� } Length of each line.......... . .... ....... . Total Length LEACHING LINE ( ] No. of Lines . ' D' Box . . ..... .. Type Filter Material .... ... ...........Depth Filter Material > " n l. ... Fou . ndation .... .... Property Distance to nearest: Well Line •-.•.»» �. Rock Filled YiltQ, . Diameter Number .........iii•, ................ SEEPAGE PIT O Depth .. ............. .. ` Water Table Depth .. Rock Size ..... . ........................................... r+d y ....Foundation ....... .......... Prop. Line ' Distance to nearest: Well ...--.. •••- ,. �? REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ...... .... ) .,. _.. a Septic Tank (Specify Requirements) ............. ...... ........ ..... ....... ......... ................. ....... ...... .. r Disposal Field (Specify Requirements) .... p F' 94.. . ................ --- _ - - ... ................. .. ................................. ........ ...................... .. .. - ....... .... ... .. ...... (Draw existing and required addition on reverse side) w' I herby certify that have prepared this application and that the work will be done,in accordance with San Jeagsrlr+ Ai My County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local.Hsialfh District.Home s+yr+er or Iitsn sed agents signature certifies the following: i "I certify that in the performance of the work for which this permit is issued, I shall not employ any person 1n such manner as to become subject to Workman's Compensation laws of California." Owner Signed ned .- �raj/'� -"........ ........ Title . .. ... .................( .. .. - (If other than owner) R DE ARTMENT USE ONLY _ a _ DATE APPLICATION ACCEPTED BY...... .... ........................... ........ .......... BUILDING PERMIT ISSUED ............................................................................................... .......... DATE .. ... .............. .... .... ADDITIONAL COMMENTS ................................................................................................. ......... .... ................................................. .................................................. .......... ......_............_.-........................ .................. ... -... .... .... ......................._........................�. . Data . . ../..� 7G y a Final Inspection by; ............................. ......._......_............ ...-.... . ' EH 13 2b 1-613 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 6/7b 3M