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FOR OFFICE USE: .................. ;;;, ... . .................. APPLICATION FOR SANITATION- PER IMIT (Complete in Triplicate) This Permit Expires I Year From Onto Issued Permit No. . eh!- f- Z 0 cl Date Issued ..7-.-~.3 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 No. 549 orli` existing Rules and Regulations: JOB ADDRESS/LOCATION 104 TRACT ..................... Owner's Name ................. ........ ............. phone ....................... . . Address ............. ...... ........ ...... Contractor's Nome._ Phone ....... ........ Lic&ise # . . ......... Installation will serve: Residence ZA$0�_rtment House M Commercial C]Troiler Court 0 Motel [] Other ........ Number of living units-. Number of bedrooms -,.Garbage Grinder Lot Size Water Supply: Public System and name ...... ......... ...... ....... Private Character of soil to a depth of 3 feet. Sand E] Silt 0 Clay Peat Cl Sandy Loom C] Cloy Loom 0 Hardpan r-1, AdobeFill Material ,41 _ If yes, type .............. (Plot plan, showing size of lot, location of system 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 TREATMENTSEPTIC TANK ------- Liquid Depth "VAZ ...... Capacity T2,.0.'0__. Type PA40L(/!A4rMoteriaI_..- Avc 5, Compartments Distance to nearest Well ------- Prop. Line LEACHING LINE No. of Lines Length of each line. !r,7,57. Total Length 'D' Box _JeS_. Type Filter Material Filter Material ....... on Distance nearest Well Foundation �..AK_Q .. .......... Property Line 0 -AV ..... ....... -SEEPAGE PIT Depth Diameter 33- Numbe*,-.:�.��='�,`,. ............ Rock Filled Yes No Water Table Depth..............."..._..__.__.Rock Size"I. ............. Distance to nearest. Well ....... %Fou1ndot;on Prop. Line REPAID /AV%nI'n#W 10r,&tr 1-!+-+- V-!+ &* n-+., i I .................. .. Septic Tank (Specify Requirements) .... . .......... .............. .. . .................. ............. — ---_---------- Disposal Field (Specify' Requirements) ..........r.._ . . ...... ............. ............. ... . .... . . ...... . ..... ..... ..».............................__ ......... _ ............. _. . ...... ............. . .......... . . . ................................... . ------------- I .......................................... . ..........................__ ; .........»................................... (Draw existing and required addition on reverse side) I hereby certify that:l have prepared this application and that the work will, , be done in accordance with San 1*04min County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following- ") Certify that in the P*rformonc* of the work for which this permit is issued, I *hall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .......... ....... ...........".: :... Owher ByTitle ....... . ................................. owner) ./fq* DEPARTMENT I1Sk_PNLY APPLICATION ACCEPTED BY ......................................... DATE .......... ...... .. ... ... . ..... * ...... BUILDING PERMIT ISSUED -------------- -------- ----- * ..................................._DATE ......... .... .... -------------------- .. .... ADDITIONAL COMMENTS ....... ................... ............. ......... ............ . .......... ............... .............. ............. ......... nol Inspection by: _j . ................... . ........ ...... 4 ........ _ ............ ---1 ....... ...... ............... ............Date . ......... SAN JOAQUIN LOCAL HEALTH DISTRICT' E. H. 9 1-'b8 Rev. 5M