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r'.�• v �� 'F�YI�I.IG �li':�1C! *3�-' �tee.� r APPLICATION FOR SANITATION PERMIT ... .... (Complete in Triplicate) Permit No. a�.:,..��.��. ............ ... ...... . This Penult Expires I Year From Date Issued Date Issued . 7� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein kdescribed. This application Is made In compliance with }County.Ordinance No. 549 and existing Rules and Regulations, J08 ADDRESS/LOCATION .... .,f.. ................. CENSUS TRACT .......................... Owner's Nome � Phone Address •--.. .C ...?�...25.......... .__ •... ... ... . .. � ............. .................................... ._ ... .............. ........... City ,,,� ......................................... Contractor's Name _ ... .�:��.• Z..,� 11.LEaense r, .�xf .� �.,.. �'=1�. Phone f Installation will serve: Residence Apartment House C3 Commercial[]Trailer Court ❑ Motel❑Other.........'..........................•...... -Number of living units)..../.. Number of room ....Garbo a Pinder .` '. Lot Size ....a-,z., Z�2. ..... Water Supply Public System and name .. .. . . .......... ...C�s1. .........-,_„...,........................... . .Private ... . ...... p v Character of soil to a depth of 3 feet: Sand 0 Slit❑ Clay ❑ Peat❑ Sandy Loam Q Clay Loam❑ iHardpan d Adobe Ek Fill Material ............if yes,type........................... (Plot plan, showing size of lot, location of system in rotation to wells, buildings, etc. must be placed on reverse slde-&Al NEW INSTALLATIONS INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK s �e... /. ........ . . ..... Liquid Depth ...�............ € ..._ capacity/,, C1 .x�i�l�' Type AXZMAaterial..4��-' . . ........�No. Compartments ..>2.............. Distance to nearest: Well .. �.,��e8 .......Foundation./cr......... Prop. Line .aS`. f LEACHING LINE No. of Lines .........•....... Length of a dh 11 e._. `�........... Total Len th ,,� �-�............... 'D' Box _. L.... Typo Fiber Material . . ....Depth Filter Material .... ... .................................. • Distance to nearest: Well . .-. Foundation A�........, Property Line .. .� ........ Diameter cr SEEPAGE PIT � Depth � -.f ........ Number ... .................. hock Filled YesNa Q Water Table Depth _. � ..Rock Size . ..f Distance to nearest, Well _ e* .�f� .......Foundation A7..';....... Prop. Line .. . ....... REPAIR/ADDITION(Prov. Sanitation Permit ............................................. Data .............. ...-------.,_ .# Septic Tank (Specify Requirements) ......................................... ._..........•---- ••••............. ................................................... Disposal Field )Specify Requirements) .................................... .....------.........................................................---•--......,.......... ............................. —........................ ............................................................................. ................_. ....................... `.................. .......... .......... .... .................... ......---..__....................................._..........................................................-................................. (Draw existing and required addition on reverse side) a"" I hereby certify that I have prepared this application and that the work will be done In�accordance with San Jo"vin County Ordinances, State Laws, ar+d Rules and Regulations of the San Joaquin Local Health District. Home owner eir lite& sed agents signature certifies the following: ' "l 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." I Signed .. ............. ....... .. . . ........ Owner By .--- ... ' . ............... .. title ...... . -- ----- ... .... ................._............. of other than owner)i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..... 10........................ ....., DATE .. . .�> ': ....................... BUILDING PERMIT ISSUED ._DATE ADDITIONAL COMMENTS ..............!......... ............. ;....................... ........................__......-........... ........--------..........-.. ............ .......-............. ......... Final lnspeetion 6y: ., r% LJ ._..'.............................. ..:...,..,............................Date ................. EH 13 24 1-60 acv. 5q[ SAN lOAQUIN LOCAL HEALTH DISTRICT 8/711 3M . 4 f