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FOR OFFICE USE: APPLICATION FOR SANiTATI04RMIT ................................................... (Complete in Triplicate) Permit No. ...7.. ..........,...I.............................. ' ." .. This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work hereii described. This application Is made in compliance with County Ordinance No. 5419 and existing Rules and Regulatlonsr JOB ADDRESSAOCATiO`N' /0 '.. /� .. fNf 1�. ..-L:Pi (..!..CENSUS TRACT ........................, Owner's Name ............ i.".f.^.. .... Ca/p.......................................,.....................................Phone ..��.: Address ........................................ .Ae' /Ile...........................................City ........................................................................... Contractor's Name .....................................0 1�............................license # ........................ Phone ........................... Installation will server Residence❑Apartment House❑ Commercial OTraller Court Motel ❑Other Number of living units,......1 Number of bedroom: jl Garbage Grinder Lot Size .... .:...._ Water Supply: Public System and name ..................................._...................._-------_..........................................Private ......, Character of soil to a depth of 3 feet, Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam Hardpan❑ Adobe❑ Fill Material ............ If yes,type ........................... (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on revere side, NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is avOlable4vithin 200 feet,) y PACKAGE TREATMENT j ] SEPTIC TANK X Size... ! />y Liquid Depth Capacity .IaN Type r�rl�= j1< Materlal.41-t No. Compartments .. - ':......... Distance to nearest: Well ....... Foundation . � Prop. Line� .. .... ........ t ....... Length of each line. i!Il� LEACHING LINE No. of lines .......... ...... ........ ......... Total Length ..... D' Box .. Type Filter Moterlal� .7�. epth Filter Material ......��..t�n.. ..... ..... . Distance to nearest, Well .....s . ....... Foundat on .....Idl,10. ...... Property Line ..... ....... SEEPAGE PIT ( ) Depth .................... Diameter ................. Number ............................ Rock Filled Yes ❑ No C Water Table Depth ................................................Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. Line ........._......... REPAIR ADDITION Prev. Sanitation Permit ... .. . I/ ( ......................... ................ Date ................... ..... .... Septic Tank (Specify Requirements) .................... . .................. ............... ........... Disposal Field (Specify Requirement .P�i' '. 5 ... .�. �� ................. r � . 7.../ .��t. ... l . ..... 1. .�.�!' ...... ..0 .�l1J��'. . . . ._....1't� .l4' �GG-' ................................................ G V (D existing and required addition on reverse side) 1 herby certify that i have prepared this application and that the work will be done in accordance with San Jonquil County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or llcer sed agents signature certifies the following: "I certify the► In the performance of the work for which this permit Is Issued, I shalt not employ any person In such manna as to become sub j ct to Workman's Comp satlon laws of California." Signed ............. .... .. Owner g ..... E' y................................. ., title (If other than owner) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..... .......... ............ ........ DATE ...,' �71 .:............ BUILDINGPERMIT ISSUED .........................................................................................................DATE ................................... ADDITIONALCOMMENTS .... . .............................................................................................:...... ................................................ ............... ............................................................................ ...................................... ......................................... .... .. / Final Inspection by: ................... G.tJ '.....................................-.........................--•-•-...............Date /. . jT.. . i iEH 13 2!t 1-613 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M