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FOR OFFICE USE: _ APPLICATION FOR SANITATION PERMIT ........_.�.��x .................�'.� Permit / iCompiete in Triplicate) ................... This Permit Expires 1 Year From Date Issued Date Issued . s Application is hereby made to the Son Joaquin local Health District for a permit to construct and install the work herein described. This application is made in Compliance with County Ordinance No, 549 and existing Rules and Regulations: i 561 �� .1� _.. L._ ._- .CENSUS TRACT .:.. .108 ADDRESS/LOCATION ,......... .... .................. .. ..... ..Phone r QQ Owner's Name ... 'A . .. (. 1" .. ? Address �� , 7..... _r... _e....... Cit Contractor's Name .. °:. tT'. i_. _. ...License # .3_(P-._3.... Phone 6C .:.. : :. j Installation will serve: Residence 11�6partment House❑ Commercial ❑Troller Court Motel.. _. []Other ......-...................g........._------ Number of living units:.. ..... Number of bedrooms �......Garba a Grinder ............ Lot Size .. _ r- Q._................. Water Supply: Public System and name -- .__...__ _-tf s4�1_ ....... ................ .......Private ❑ Character of soil to a depth of 3 feet: Sand D Silt❑ Clay N1 Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan❑ Adobe-0, Fill Material ............ If yes,type ............................ IPlot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size................................................ Liquid Depth ..............:........... Capacity ............. Type ..... Material No. Compartments Distance to nearest: Well ....................................Foundation ..._........__.__ ---- Prop. line ...................... LEACHING LINE [ ] 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 [ ) Depth .................... .Diameter--.-n ---- Number ............................ Rock Filled Yes ❑ No Water Table Depth ................Rock Size Distance to nearest: Well ----•--•..........:............... Foundation .................... Prop. Line ......................,;� REPAIR/ADDITION JPre v. Sanitation Permit# ................................ Date .................................. Septic Tank lS e •fi ) Requirements) -•----......_T ... a ,..,__ ..?•� .:. �� .. Uel --._..._----------------- Disposal Field (Specify Requirements) -----�..qnz .`.t.r..� . ............................. ...........•--------......-------------• A's ..... ..............•-••---......._..__..- ..................... _..... _ ------------- -------=------------------------ - ...................................=........................................................... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen. sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." r_ Signed ......... . ._ .. ..... . ..............•-------•--• .....-.........:...............-•--- Owne BY -•--- •..---...._ �� -r/V�f�3 --------.... Title '' . ..--- .................... (If other than owner) F DEPARTMENT _USE -ONLY APPLICATION ACCEPTED BY ..... .... ................................................ ............ DATE .. ._ ............... BUILDING PERMIT ISSUED ...... ...........:............................................. ..DATE AD ITIONA COMMS. = . . ..................I............. -...•-•-.......................................... -... -................. ...... ...... .....:....-•--•..._......•---.. -, ...............................:...................................................•--..-----=--------- -----------•---•---------------- -------- - ......-----•------••-- ---....._-- ...... Final Inspection by: . . ...........................................................:......Date .:, : ... . . . r J QUIN LOCAL HEALTH DISTRICT .. 11 9G , ..,, 7179 3 M