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FOR OFFICE 4JSI:: iAPPLICATION FOR SANITATION PERMIT ... ..._•................................ I 1l to Permit No. .....................�- Complete In Trip ca I .................................. Date Issued''..`77 1 ........ ................ This hermit Expires 9 Year From Date 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 compliance with County Ordinance N . 544 and existing Rules and Regulsttlana: PrP. ............................................... •.,-- 'x_.. 1.C. ..�................ .. .CENSUS TRACT .................... JOB ADDRESS/LOCATI r Owner's Name ". .............Phone,.. fes• d-•- Address ' ..... -� ° .�of�. Phone .. ✓�� Contractor's Name ..4. --- •-•-••••.....• '== :_._.._.....Llcenise # Installation will serve: dente p rtmeht Houses] Commercial❑Trailer Court 0 , ' Motel 0 Other 1 Number o¢ living units------------- Number of�bedrooms Garbage Grinder ..-•----.._. lot Slze --.-• -•---•---... . .. =:. ..... Water Supply: Public System and name _x _ _ -•••-...--,..--•----_•---•...............__.................................................Private err �: Character of soil to a depth of 3 feet. Sand.❑. Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom Hardpan 0 Adobe❑ fill Mcterial ............If yes,type............... ............ 7 IPlot plan, showing size of lot, location of.system In relation to wells, buildings, etc. must be placed on reverse aide.) h1 NEW iNSTAILATlONa (No septic tank or.,seepage pit permitted if public sewer.Is available within 200 feet,) � PACKAGE TREATMENT [ ] SEPTIC TANK I.] Size................................................ Liquid Depth .......................... Capacltyij fJ ...... - Material.. No. Camparfnnenta i _....�--------t3 ....r_. .............. • Distance to nearest:4Well;.�Qa .Foundation I ... ... . _ . ;:. -- -.. Prop. L ne LEACHING LINE [ No. of lines '""--------—Length of each line............................ Total Length ........... ............... {r r 'D' Box ..I......_ Type Filter Materlal -....Depth !Filter Material _.��............. . .... .... 1.} a Distance to-nearest: Weil .....f.._.__.. ... foundation ....... Property line :..............::....... . Rock Filled Yea 0 No SEEPAGE PIT [ I Depth ............... Diameter Number Water Table Depth ..............:.................................Rock Size .-••----.... ................... t Distance to nearest: Well .......:...... ..___........Foundation __..............._.. Prop. line .........r.......... REPAIR/ADDITION(Prev- Sanitation Permit ._.... Date ...............) H --- �................ _..........__...--- �` Septic Tank (Specify Requirements) .................................... .. --.--.....„............_._.._... ....:.k........ ....... ..... r "Disposal f=ield (Specify ............... 4._:......... '' ......_.-_.._........_.__.•_•••_-•-•-•-•--......A......._............._............................ ................ `• ...-•--•----...I................... ``' •--.�_.......... •-••••-•-....-----. ..•-••-- .. ...._..................._............. .........................................+ �(Draw�xisting and required addition an reverse side) ' i x i I hereby certify that I have prepared this applicatlon and that the work will be clone in accordance with San Joaquln County Ordinances, State Laws, and Rules -and Regulatlona-of.the San Joaquin Local Health District. Home owner at "cow sed agents signature certifies the following: .' �"�" �-�_ F "I.certify that In the performance of the work for which this permit is Issued, I shall not-ampiay any person in such manner as to become subject to Workman's Compensation laws of California." Signed ....-. .................................................. Owner !�ye �Itle ............................. ... ....__._............._...._.... . .......... .. if other than owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED :;BY... ._. ' DATE ,.. BUILDING PERMIT ISSUED ........DATE ........... ADDITIONAL COMMENTS ........................................-_-.-.-............................................................I...................... :..... ......--•--•........................•---•-.......---...-.-........................_.._......--••- -................................................I——............... ....._..... ................. ..................I.............I...............I....__........ ..................... ......••......... _.:. .._..._ .....• ,... _ ........._... Final Inspection by ............................ ..... Date s�.er,7 ...- ................... q. , EH 13 2h 1-60 R©v. SAN JOAQUIN LOCAL HEALTH DISTRICT /7h 3N