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APPLICATION FOR SANITATION Ph�+IIT ?.S : 21. . .............. :. .......... .. Permit No. �; 1.... .... ��: ..................... (Complete In Triplicate) ... S 7 ....... . . ' Date issued .'�`:f.�.-,--- r .� ... ........:............ This Permit Expires 1 Year From Date Issued IWJOBADDRESS/LOCATIOVN Is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein h`s application is made In compliance with County Ordinance No. 549-and existing Rules and Regulatlonst.. l©.lD..�-. .. a ..Co . -..l -CENSUS TRACT .......Owner's Name ........ ii' .., Ll ...............................:.... . ....................................Phone :. ... , Address ..... �.' .........._.....................?.! /�Jle...--••----.....-----............_.........City ..................... �....... 4! ....... ...... .........License * ..... ...._............. o ! Contractor's Name Installation will serve. Residence❑Apartment House(] Commercial❑Traller Court ��. Motel ❑Other............................................. Number of living unitsk...... .... Number of bedrooms ........I..Garbage Grinder ............ lot Size .... .............. r .: Water Supply: Public System and name .........................................................-........._..........................................private Character of call to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑• Sandy loam ❑ Clay Loam�. Hardpan❑ Adobe❑ Fill Moterlal ............If yes.type ............... ........ . .. . {plot plan, showing size of lot, location of system In relation to wells, buildings, etc, must be placed an reverse side.) NEW INSTALLATIONS (No septic tank or seepage pit permitted If public sewer is av labl ithin 200 feet,) ,. ll11 PACKAGE TREATMENT ( ] SEPTIC TANK Size....T.. . .Q liquid Depth ...........................I Capacity .fc9Type i�.C-1C- /. Material-6 No. Compartments .: ..........0 Distance to nearest: Well - Foundation . . ......... Prop. Line b ' LEACHING LINE ',� No. of Lines ..........I............. Length of each line.........j� ..........Total Length ...... .........0 ....Type Material .. ••� Distance to nearest, Well .....s /�r�....... Foundat on .....111�....... Property line ..... ......... SEEPAGE PITO Depth. ...........I........ Diameter ................ Number ............................. Rock Filled Yes ❑ No u ;I1. Water Table Depth .............. ..............................Rock Size ................................ i` Distance to nearest Well .. ..................................Foundation .................... Prop..Line ...................� REPAIR/ADDITION(Prov. Sanitation Permit 0 ............................................ Date ..................................I Septic Tank (Specify Requirements) ........... . .. .:.............. ................. .......... Disposal field (Specify Requirement ..o�` �' ' `rf.. � . �/� dJ ..... • ....... ........................................ IM (DrVexisting and required addition on reverse side) ' I hereby certify that I have prepared this application and that the work will be done to accordance with San Joaquin �I. County Ordinances, State Lows, and Rules and Regulations of the San Joaquin Local Health District. Home owner of licen. sed agents signature certifies the following: "I certify that In the performance of the work for which this permit is issued, 1 shalt not employ any person In such manner as to become sub ct to Workman's Camp cation laws of California." Signed ........ '.. .:..52 �........ -E�,.................................... Owner ........... By ..... ........................................................ ...... ... . ... ............ .. ....... ......................................... Title ................................................... (if other than owner) t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ......... .. DATE ....� . ..7` ....•<• BUILDING PERMIT ISSUED ........ ........ - .........DATE. . 4 ADDITIONAL COMMENTS .. . . ...........................................------•--•----.. .. ....---......--.................. ..... .... ............._.........-..................... '1 'j ......... .......... ............ ......................... ..::'•:.............. .;....,.......: ...... .•_........I....._.................................. .. ... 1 Final inspection by. .......................& ..�....... Date . ./. .. .. . .. ........................ ..... j -,EH 13 24 M l'-60 aov. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT B/7h 3M