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FOR OFFICE USE: ' 3 APPLICATION FOR SANITATION PERMIT {' � ...-----Y----- IComplete in Triplicate) Permit No. ..!'--)....... ............................... This Permit Expires 1 Year from Dat*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 compliance with County Ordinance No. 549 and a Istin Rules anal gulations: ! t � � 67 JOB ADDRESS/LOC Aoi ....�CI:NSIJS ACT ...- -.-__ ,. _. . . __ : ..... . Owner's Name .............Phone 141�.5�= �� `. Address — City --.f.-4. 0 .............. ._..- Contractor's Name ---- ,. ....... -'?' G ... *...............License * ........................ Phone 7 Installation will serve: Residence(Apartment Houseo Commercial❑Trailer Court ❑ IF Motel ❑Other ............................................ Number of living units:..... -_-_-- N umber of bedrooms__-.Garbage Grinder ............ Lot Size Water Supply: Public System and name ..........................................--.................................................................Private Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe 0, Fill Material ............If yes;type............... .... i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: ( (Na septictank or seepage pit permitted if public sewer is available within 240 feet,y PACKAGE TREATMENT [ ] SEPTIC TANK] ] Size.......................................... ... Liquid Depth X Capacity A- •-----•---_ Type .................... Material---- ----------------- No. Compartments 0 Distance to nearest: Well ....................................Foundation ...................... Prop. Line ......................ill LEACHING LINE [ j No. of Lines ------------------------ Length of each line------...................... Total Length ............................. D' Sox Type Filter Material ....Depth Filter Material ................ o nearest: Well ........................ Foundation -..:--...........-...... Property Line . Distance t � _ SEEPAGE PIT [ 1 Depth ....:............... Diameter __.............- Number __.... ................ Rock Filled Yes ❑ No {� Water Table Depth ------------------------------------------------Rock Size .......................... 1 Distance to€nearest: Well ........................................Foundation ___ ...... Prop. Line ---._...._........._�T b REPAIR/ADDITION(Prev. Sanitation!Permit# _ Date Septic Tank (Specify Requirements) ____ r Disposal Field cify Re uire i a 'f3 meats] ¢- S~o t -------------------------------------------------- - . - -- - - --- -- 33- CL (Draw existing otS`d requir ad�iarff on reverse side I hereby certify, that I 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. Hoare owner or liven. sed agents signature certifies the following: "I certify that in the performance of the work for'which this permit is issued, 1 shall not employ any person in such manner as to betAme subject to n's CornpensafieVi aws of California." Signe �• f -� _l `� ----- a-.... 1�L�' . Awe A: By ........ �\ Title . t (if other than owner) FOR DEPARTMENT ALISE O LY APPLICATION ACCEPTED BY -------- k------------- -----•-- DATE ../l-fic�w7 BUILDING PERMIT ISSUED �*''� --.....DATE - ..-._..-........... .......• - ••--- - ADDiTIONAL - COMMENTS --- ------•-�•-------------- ---------------- ----•- •------: .. ..-------- ,. ------- ----------•-- ---------------- . - _ r - ----- � _._._..._. ................................................... ---------------------------------------------- - ---------_-------------------------------------------- _ Final Inspection by: �� •- e .-- _ . -_•.Dat ',. lo,-"`_-- 13 21a 1-68 Rv• SAN JOAQUIN LOC6L, HEALTH DISTRICT 8/7ht 3M