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FOR-0FFICE USi: APPLICATION FOR SANITATION PERMIT rf !1 ................................... . . . (ComPermit No. 1pleteIn Triplicate)teh) rte' ...........:....'..................... ....... ...... This Permit Expires Y Date Issued Date I Year From a Application is hereby made to the San Joaquin Local Health District for a permit to conskki and install the work herein described. This application Is made In compliance with County Ord once No. 549 and existing Rules and Regulatlonsi JOB ADDRESSA ION .:R�1✓r0.w� �f. edit..... C3 .............................CENSUS T .......................... iE: .,Qs m. .... .Phone�['Q �:.Owner's Name ....... ! .. ...... ....ftr ...........................CityIPL:F"t`f ................... ............... -- Liicense � ..... Phone I Contractor's Nam __ Jf --- ........................ l $ Installation will'3ervees Residence❑Apartment House Commercial❑Trailer Court ❑ `Motel❑Other ,!4 Number,of living units:--_f------ Number of bedrooms ---Garbage Grinder ............ Lot Size .. •e C�'_ ....... Water Supply: Public System and name ................................----•..................---•................................................. Prlvats� Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ day Loam . Hardpan El Adobe❑ Fill Material ............If yeI',type--------------- ------------ (Plot plan, showing size of lot, location of system I In relation to wells, buildings, etc. must be plated on reverse slds.# NEW INSTALLATIONS (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 44 PACKAGE TREATMENT SEPTIC TANK( I ' Shoe..:.,�................................ Liquid Depth ......._ ................. Capacity A o..... Type Material. 1 '� No. Compartments .. .. ...... Distance to nearest: Well ., / . Prop. Line . ....................Fou anon. G .......... - ----......... LEACHING LINE �No. of Lines ........ ---. Length of each line-_ `�.........--- Total .Length ...J> ................ 'D' Box Type Filter Material � o l`�...Depih filter Material (................................ .. * . , Distance to'nearesh Well . 35. foundation ..�-i�r-�............... Property Line ... .. .. SEEPAGE PIT W Depth Q;25......... Diameter ' ......... Number .... .... ....... Rock Filled Yes/Z No ❑ " Water Table Depth ............. .................Rock Sias -��.��.�--- Distancro nearest: Well . . ....................Foundation0 �........ Prop.-ll_r ei-----.--- REPAIR/ADDITION(Prev. Sanitation.Permit# ............. 7........._.•-..--.------ Date ................................ .f J r SepticTank (Specify Requirements) ......................................... r-....................................................................................... Disposal Field {Specify Requirements) ' " •---•....................................•----.................................... ..................................................................................................................... (Draw existing-wind required ado dition n reverse slde) 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 the1on Joaquin Local Health District. Hoene owner or licen- zed agentssigo-aturs iertifEes the following: "i.certify that in the performance of-the—Work for which-thls permit is Issued, I shall not employ any person In such manner as to become subjec to Workman's Co a atlon laws of California." Signed ....... ............... owner r liy .... .................................... Title ...................... ....---.............. . .. ..... ( . .... .... Iii other than o FOR DEPARTMENT USE ONLY s APPLICATION ACCEPTED BY ............................... ..:......----•......_.........................-•-----•--..._.... DATE ......3.: .'Zf.............. BUILDING PERMIT ISSUED ................................................................................---•----..........---......DATE ........................ .................. ADDITIONAL COMMENTS ........................a ......•----......................................................................_........I................. . ----••...................... ............. ..... . ..... ..._.-................... ............ ......._.... Final Inspection by: ........Date ........ . . .... ... .... ......I.......... Eli 13 24 1-bfl Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 74 3M