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FOR OFFICE USE: • APPLICATION FOR SANITATION PERMIT ........ ............._. ---- IConplete in Triplicate) Permit No. ..7................ This Permit Ex Pres 1 Year From Date issued ©ate Issued .--s..... .`. 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 and existing Rules and Regulations: JOB ADDRESS/LOCATION .....................................CENSUS TRACT Owner's Name r .......................... ..............rte.. Ph one Address •� -- - ^---. ...._... .....City ...�........... Contractor's Name rrr _._��•• €cense # ...... Phoned jQ.� Installation will serve: Residence❑Apartment Housef] Commercial❑Trailer Court ❑ Mote} ❑Other............. Number of living ' umber of bedrooms-3 Grinder ......__..__ Lot Size Water Supply: Publicunits:Character of depth System and name ................................ -- Private { p et: Sand❑ Silt:❑ Clay ❑ Peat© Sandy Loom ❑. Clay Loam, t Hardpan❑ Adobe 0 Fill Material .... ....... If yes,typo............... (Plot plan, showing sizeof 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,( 6 PACKAGE TREATMENT I ] SEPTIC TANK ] Size............... 6 .......•••------............-•--- Liqu€d. Depth Capacity .: Type .................... Material--- -----------•----- No. Compartments .......... Distance.to nearest: Well ....................................Foundation ...... Prop Line LEACHING LINE No. of Lines _._:_.__ --•-----..._. Length of each line-.CO11.`:...r-r_4.Q:r__-- Total Length D' Sox .__.:_..._.. Type Fitter Material Depth Filter Material � I t E ... Distance to Well, � _ Foundation ....... Property . . Pf0 arty Line ....... d-'$iameter �/ Depth ..... - - _ _�7//,rNumber ---_-.-�---- --_-- Rock Filled Yes ,1�N..o...•❑S4ALt .... � Water;Table-Depth .. .Q...... ...................Rock Size lnearest: Well -.... .........................Foundation -707 Prop. Line / © 1 Distance to ......--•-- = i ,.� REPAIR/ADDITION._.�.. Y q Permit 94` -----..::..-..................-............. Date --..------•--------•--•-----•-----} Septic Tank (Specify Re uiremen (Prev.( Sanitation irl- t�1 . --• • -••---. ....... .............. ................. - _. Dis osal Field (Specify Requirements) ...... _.__ .............- .._ - -•--- � ------••------------ ------- -------- •--------------- -------------•---------------- -••-------•----••---•••--. ------•-•-•••----- ------.... ..:---------------------------- (Draw existing and required addition on reverse side} I hereby certify that t have prepared this application and that the w- -ark will be done in accordance wltfi`Sdn Joaquin County Ordinances, State Laws, aria Rules and Regulations of the San Joaquin Local Health.District. Home owner or liten- sed agents signature certifies the following: "I certify that in the pe rmonce of the work for which this permit Is issued, I shall not employ any person in such manner as to becorn suect orkman's•Com nsatio :n ws of California." Signed - bj - -- `� -, i--- Owner s BY ---------------------------•-- ••-------------- --------- - ' llf other than owner} E.j ------ i FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY ...... -----------•------ -------- -------- DATE -.`:..'Z .'_A'- G -PERMIT ISSUED -•-- ---.... ---------------------------------------DATE ...... ............... . .. ..... ADDITIONAL COMMENTS --------------�`I ---------- - ------------ --------------- ...... ------------------.................... ._..---------------------------------------- Final Inspection b EH 13 2h 1--6$ Rev. 5m .................. . _. Date .../ Q`--�-•-------------- --- � SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M