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FOR OFFICE USE APPLICATION FOR SANITATION PERMIT Perini!No. ..�5._. 3..1 .......................................... (Complete in Triplicatef .......... .............................................. Date Issued s .........................................................I This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install th work herein described.This.application-.16-made i compliance with County 0 dinance No. 549 and existing Rules and Regulations: ( Ll B A R . /1. ,/ -.. t CENSUS TRACT .......................... JOB ADDRESS/LOCATION �.. '� •' C � Owner's Name . .... f ..... .. .............................. ...............phone ......_.. Address ................................... . .._ �'l._/..._4`%��............ City -` .... .................................. �! 11. _-__license # ........................ Phone ...._.._...................... Contractor's Name ......................... .... - - -......_ Installation will serve: Residence4Apartment House Commercial CITraller Court ❑ I ' - Motel ❑Other� # -•--•-•-•...............•----•---•-•_.... � Number of livingunital...... Number of bedrooms Garbage Grinder ... Lot Size ............................................ Water Supply: Pblic System and name ...........................___..............._....... ..........................................Private Character of soil to a depth of 3 feats Sand D Silt❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loam Hardpan❑ Adobe❑ Fill Moterial ............If yes,type ............... ............ _ !Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) NEW INSTALLATIONt (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} V PACKAGE TREATMENT [ ] SEPTIC TANK Size................................................ Liquid Depth .......................... JO Capacity --- Type ..... Material...................... No. Compartments ...................... Distance to nearest: Well Foundation ...................... Prop. Line ...................... LEACHING LINE [ j Na. of lines ...............•---..... length of each line....--:_................_._. Total Length ......................... ..9 'D' Box ............ Type Filter Material ....................Depth Filter Material ..................... ................I Distance to nearest: Well .. Foundation ........................ Property Line ........................ SEEPAGE PIT [ [ Depth ..................... Diameter ................ Number ............................ Rock Filled Yes (3 No i❑ . ' Water Table Delith ......Rock Size Distance to nearest: Well ..............Fbundation Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# . Date � .....,T.y�.-_. ..... Septic Tank (5per 3fl Requirements) ••-...... . ••• ........ Disposal Field (Specify Requirements) ...... ..................................................••••...........•.._.._..........._.._...----..3 . .....................................-............................................................................................-..-....., .__..........--•----.............__.........------•mob ..................... ...--------•--..__............_.__.__........-.----•--_.•----...__---._.._..........----•--.............-----.... •---.._.--------------------•--- 0 (Draw existing and required addition an reverse side) ' 1 hereby certify that I have prepared this application and that the work will be done In accordance with Sam Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health Distrid, Hem* owner at )item- sed agents signature certifies the foflowing: "°I certify that in the performance of the work for which this permit Is Issued, I shall not employ any person In such manner E as to become subj to Work ompensaition laws of California." j grad .. . ............................................................ . Owner ........_ yitl$ . other than owner) ! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -......--- • .......: `-•---._ ..... ._......<:......................... PATE ... r. BUILDING PERMIT ISSUED ....... ................ E-.......--..___ - ADDITIONAL COMMENTS �- -••-AVE,•. --•--- ......I....................... •-.---......_ . .................._.-._..... - - ----------•••-•......................, -.................••------._..............- __....---- ................................. •--•-----•... ............................... 1.......-- .... .................... ........Date - ...... ...... ... Final Inspection by: .-._. ... .................................... .�--• EH i3 2L }-68 V. 5 t SAN JOAQUiN LOCAL HEALTH DISTRICT 8/7b 3H