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FOR OFFia USE: APPLICATION FOR SANITATION PERMIT - .................. .................................... (Complete in TrIpiicate) Permit No. .�-...-- . ................................................. ..... This Permit Expires ] Year From Date Issued' F Dab Issued .: �.:3..... r Application Is hereby evade to the Son Joaquin Local Health District for a permit to construct and Install the work herein described. Thio application Is made In compliance with County Ordinance No. 5:49 onj existing Rules and Regulations, JOB ADD..R.ESaS/;0CAT1 `. ._.. ...- - -•-- --- ,Y .a_.. -- - .._ .. "CENSUS TRACT Owner's Name ... .. ., ............ Phone .................................... Addressi, --- -• - ...............City .............-----------. .....................::..:. rn Contractor's Nawhe ..__:.License # Phone .............................. ' Installation will serves Residence❑Apartment Hoummercial❑Trailer Court Motel❑Other... 1�_ Number of living units:_---~.._ Number of bedrooms ==rn--__Garbage Grinder ............ Lot Size I Water Supply: Public System and name ........ ............:......_._..................... .._.._..................................,......Privat .. } Character of soil to'a depth of feat: $and❑ Silt[] Clay ❑ Peat❑ Sandy Loom Cl Clay loam Q� . ,. Hardpan❑ Adobe❑ Fill Material ._.-_....... if yes,type ............... . ' f (Plot plan, showing size of lot, location of system to relation to wells, buildings; etc. must be placed on reverse side.Y NEW INSTALLATIONS !No septic tank or see age pit permitted if public sewer is available within 200 feet,)' Ca ci �.lEl��._... �+-�.*�J�.:..� �. `:.�� Liquid Depth ._..:�`:.�. �' _ PACKAGE TREATMENT [ � SEPTIC TANK� -- ••••--•-----••• material __.. •.... _. No. Compartments ____...�:-•-..-^.'- pa ty . Type b �.,� p ......•,fo-_ Distance to nearest.• Well ..Foundation GV/11- Pro Ltne ... LEACHING LINE [41 No. of Lines ca ........... length of each line.......... ••-•__---. Tota! Length ...,.l.J'r.� .........Q , F t D' Sox / Type Fitter Material -6-.....Depth Fitter Material .-JI...".. .. Foundation Distance to nearesh Well .._........._., .. . .... Property Line SEEPAGE PIT [� Depth P--� Diameter _.. .. . Number -- -• �-f � -••�-- -------- ......`.. Rock Filed Yee No Water Table Depth ... ....---•--••---....Rock Size,....... Distance to nearest: Well -5-4- .................Foundation --:.._.:,/d Prop. line ...� - REPAIR/ADDITION(Prev. Sanitation Permit# ........................................... Date .............. .:.•---•-----•� Septic Tank (Specify Requirements) ......................................................... .......... .......N:. 1.... ........._:....... .. Disposal Field (Specify Requirementsi ----••....................._......---..._ ..... .::•_=:...1:-:.. ............................................................ A •-•....... .......................................... ..............I........................... ........I............................................................................... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will he done In accordance with San Joargain County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health DistriN. Home owner or Ileon- sod agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I *hail not employ,any person In such manner as to become subject to Workman's Compensation laws of California.*, Signed g ._..._... ................. Owner BY .......................................... - �z! ....-.. 7itla .. � .................... (If other than owner) t - FOR DEPARTMENT USI: ONLY APPLICATION ACCEPTED SY -. . - _ ......... DATE BUILDING PERMIT ISSUED DATE ADDITIONALCOMMENTS .............:... ..........•-•--•---...._...................._.........-.......-----•----......................-.-............................................ ......................... .................---- --•-• .............-.........-..................-..............................-.......................................................... .... ................. .......... Fina( Inspection by: ....-- .....-. .... .................................................I................I.....•Date .....-�.,�.0.-........................ S 13 2h 1-6 dOv• 5M SAN JOAQUIN LOCAL HEALTH DISTRICT s/?t, 3M 9