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FOR OFFICE USE. - 1.6,.A ................. APPLICATION FOR SANITATION PERMiT 76 s-5'3 iContplete M Triplicate) Permit NO, .................... ...........................................I........... _ .................... This Permit Expires 1 Year From Date Issued Deft Issued ....'........:..... Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliances with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOCA ION � ��.1.��, /t om ..CEI�U TRACT .......................... Owner's Name ..-_ y... ._ ..x r................ ................ ..................Phone ......... .......................... Address 1��.. 1....__. ��"..... "'.._< .......City .._,��.t... . . .... ...... :J. .�-:-G.........•..-..---- n... Contractor's Name .-- • is iE.��.:...: T=`` ...t.- ....License # � c .�j. Phone ............. ... . Installation will serve: Residence arrtment House❑ Commercial❑Trailer Court 0 Motel ❑Other ............................................ Number of living units:....------- Number of bedrooms ...�-----Garbage Grinder ............ Lot Size Water Supply: Public System and name ........................................................_...................................................Private �f Character of sail to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ Hardpan[]_Adobe 0 Fill Material ............ 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 INSTALLATION: (No septic tank or seepage pit permitted If public sewer Is available within 200 feet,) (� PACKAGE TREATMENT j ] SEPTIC TANK; ] sin................................................ Liquid Depth .......................... . V Capacity ...... ------ TYPO -------------------- Material............---------. No. Compartments ...................... Distance to nearest: Well ....................................Foundation ...................... Prop. line ..................... LEACHING LINE j J No. of Lines ........................ Length of each line..........................--. Total Length ............................ 'D' Box .......-.... Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT { j Depth .................... Diameter ................ Number ... ........................ Rods Filled Yes ❑ No Water Table Depth ................................................Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prov. Sanitation Permit# ..........................................•. Date ..................................) Septic Tank (Specify Requirements) ................----------.....- - -..._..�.......... . Disposal Field {Specify Requir en � l?� �' �.., -. . . •--••• ........ .�_...._ t E _ ...--•- ..: ............................................. x........ �-� ----.. --- _ �r . . ... . . ... -- - -- ---- - -- (Draw existing and quired addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accordance with Sat Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Hearth DkMd. Home owner or Rahn- sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to Workman's Compensation laws California." Signed . ' � Owner ---- --- By iNe .. ►.,Q ztRe . (If other than ow FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY._�'..0 _'.._. _ ............----.............. --------.--- - ............. DATE '......__....� . BUILDING PERMIT ISSUED ........ ................. .......-....................................DATE . ......................................... ADDITIONAL COMMENTS _....... .................... _............................. .. ............ --------- ------ .......... ................... ................. ......---....................................................---............ ----------------------- --------------- *......•--. ..---- - .......................................................-............-.............. Final Inspection by: -------- M ...............��... SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M