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FOP OFFICE USE: a APPLICATION FOR SANITATION PERMIT -----: ------ G_, .................................. .... {Complete in Triplicate) Permit No. . ....• . ............... This Permit Expires 1 Year From Date Issued 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 compli ince with Co my Ordinao. 549 and existing Rules and Regulations- in JOB ADDRESS/LOCATION . .-- - ........... ..........4A.Xin If................CENSUS TRACT ....Ca16--............ Owner's Name .. /._(,)(�� .................................... ..`.Phone ......... .......................... Address l/ � .... ..... x!/11. city `��l Y ! i�..�`-- -- --------------- --•-.. Contractor's Name 2 .....License a Y��. °.. Phone � `Zl Installation will servo: Residence JeAportment House f] Commercial❑Trailer Cqurt 0 lMotel E]Other..........................•_................ nn Number of living units:....(------ Number of bedrooms ---_...Garbage Grinder ............ Lot Slzel� .............. Water Supply: Public System and namePrivate ............................................................................. Character of soil to a depth of 3 feet: Sand'M Silt❑ Clay ❑ Peat❑ Sandy Loam o Clay Loam ❑ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK f l Size.-AlO0.................................. Liquid Depth ..................... 620-U 4 P Capacity I+2Q Ck--.----- Type 6��0-U4.t___.... Material.l3_L+1 --------- No. Com04 partments .X. .�......-- ,qe1*Ja//1 Distance to nearest: Well .-_rO.. "..•.k..............-Foundation ..1.41`.......... Prop. Line .--5-17........... � LEACHING LINE No. of Lines ________________ Length of each line------7.0................. Total Length 70..x ................. 'D' Box . __... Type Filter Material AV.?.........Depth Filter Material ............................................� Distance to nearest: Well __5...4...f-.f•_...r. Foundation 110-1... ........ Property Line X.71............... ept .................... to able Depth ck Size Di tante nearest: Wel --- --------------- --Foun n ..--------.. ...... Pr Line ---- ................. . REPAIR/ADDITION(Prev. Sanitation Permit# ........_---------------------------------- Date .............................. Septic Tank {Specify Requirementsl ---------------------------------------------------....--------------------------- -------- - -- -- Disposal Field (Specify. Requirements) ( C-----L.tl! ` .. IZIX�111/5. - ....................................... (Draw existing and req fired addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Home owner or licert- sed agents signature certifies 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 as to become subject to Workman's Compensation laws of California" Signed ------------ BY l Owner ........ ...... Title -------•----------- ........ (If other than ?wwner) JBOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYDATE . 2. .�b�7L................._.: BUILDINGPERMIT ISSUED ._.__.-•--- ------..._.._.. .............•-------••..................... .....................................DATE': ...... •---- ...........:----- ADDITIONAL COMMENTS ----- --- ---------•---•------ ---------- --------- ------ ---- ---- ------------ ---------- -•----------------------------- ------------ ------------.....--------------------------------- . ------------------------------------ --•- ---- -- ------------ .............................. -- --- Final inspection by: .. ----•---•---- --•-----_•.Date - �� 2 � 1 SAN JOAQUIN LOCAL HEALTH DISTRICT �7It 3M