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MR OFFICE USEs APPLICATION FOR SANITATION PERMIT ,7 7_."S . (Complete In Triplicate.) Permit Na. ..................... ....................... ....... .................. . . This Permit Expires ! Year From Date Issued Dote €slued�. .`.7� Application is heresy evade tothe Sean Joaquin Local Health District for a permit to construct and install the work herein described. This applicationis made In compliance with County Ordinance No. 549 and existing Rules and Regulationit t JOB ADDRESSAOCATION ..:................CENSUS TRACT ............ i. Owner's Name � - .. .................................. .......................................Phone la."'� �c _.. sAddress ............................... ........ w_._......................................................City ......................._........................................... .... Contradar's Name :.t<��.-.�,,�._r:+ - ---- -•-------•-----•-••-•............................11 d'•` �.�...f�.. License 34Z one Installation will serve: sidence❑.Apartment House Q-Commercial-Gkolfer Coin 0 _.. _ . MoteE❑4the"r= =-------------------- - Number of livin>d units:............ Number of bedrooms Garbage Grinder Lot Size Water Supply: Public System and name _� . ... ...... ._ ..................... _. � ._.........................................Private❑ ---- Character f.;oil to a depth of Vets Sand❑ Silt❑ Clay ❑ Peat❑ Sanely Loom ❑ Clay loam ❑ , t. ` j 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 reverse side.) NEW INSTALLATION: FINo sap is tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGETREATMENT, ( }y f SEPTIC TANK( Size........................ ..._.................... Liquid Depth .........................)) j 'Cap ... TYf� - ......... Material.....= Na. Compartments -........._. ..._.ill .... ' Distance 'to nearest. Well .....................,Foundation ...................... Prop. line .._......_..__....... LEACHING LINE D No. of Lines - Length of each line._..:�fJ ............... Total Length ..-1�� ._....:......s 'D' Box --1....... Type Filter Material .Depth Filter Material - .. � . , Distance to nearest: Well ........................ foundation ........................ Property Line ........................ SEEP [ 9 Depth ..:................. Diameter ................ Number ------ ............... Rock Filled Yee ❑ No Q ' Water Table Depth .............Rock Size ... .... c � 1 .. ...................Foundation i Distance to nearest: Well _.- ....-. Prop. Line REPAIR/ADDITIbN(Prev. Sanitation Permit# .....................................:...... Date .... .......................... { Septic Tank {Specify Requirementsl .......................................• -----......_............................................... . ..--...... ........... i 1. �t Disposal Fiala )Sped Requirementsl�. ._. ..: .._.. - --.: . - ._...... - ..........................•--•......_.... .... - ...........- ................................. •--.....:............... ..................................I....................... I (Draw existing and required addition on reverse side) I hereby certify th+lt I have prepared this applicatlon and that the work will be done in accordance with Sart Joaquin County Ordinances, State Laws, and Rules and :Regulations of the San Joaquin Local Health District. Home owner. or liven-sed agents 4f Slim tertifies 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 i' as to bee a subject Workma� "s Compensation laws of California." Signed !/ . ......................... ..................................... Owner By ............................. .............................. ........... litle ....................... ................_.............._................_ : i Ilf other than owner) _ FOR QEPARTMENT USE ONLY APPLICATION ACCEPTED•BY .. ..... .. .. ... DATE,., .,:W..: ...,.:.. BUILDINGL PERMIT ISSUED ------..................... ..__.._.....I.....................•• ..-•-••----........__.........................DATE _.......................................... ADDITIONALCOMMENTS ....................•---•-----•--•------------............................................................................................................. ......... ............................. . ....._........ ..... ---- - --....._. ........ . .. ................................_ .. .:...._•....''. . .................................. ............ ... Final Inspection by: . ........................................•-• ....Date EH 13 2h 1-61) Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M